A 61 YEAR OLD WITH COUGH AND SOB

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.   

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 61 year old male came to op with the chief complaints of sore throat and cough since 5 days. And sob since 1 day.

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 3 months back then then he had weakness of bilateral lower limbs which was sudden in onset for which he consulted doctor and diagnosed have having low potassium and given medication and now pt is unable to walk without stand

Now pt having cough since 5days which is dry type for 4 days and associated with sputum since today morning which is yellowish white in colour non foul smelling , not blood stained and pt complaints of chest pain while coughing , and also epigastric pain

Decreased urination since 10days

Pt is having sob grade 3 since yesterday evening and also had foreign body sensation in throat since today morning

▪No H/ O fever, cold, chills , rigors, palpitations, nausea , vomiting, loose stools , no odonophagia, no dysphagia

PAST HISTORY

Known case of diabetes since 15 years ( and on regular medication - GLICLAZ- M 1/2 tablet daily)

Not a known case of HTN, asthma, epilepsy, TB

SURGICAL HISTORY-

Patient had a history of appendix surgery 15 years back(after that he stopped collecting toddy and started farming and he grows patti)

PERSONAL HISTORY 

DIET- mixed

Appetite - decreased since 3 days

Sleep- adequate

Bowel and bladder movements - regular

Habits- used to consumes toddy 15 years back and stopped consuming since then

FAMILY HISTORY -not significant

GENERAL EXAMINATION

Patient is conscious coherent cooperative, well oriented to time place person

Thinly built and nourished 

Pallor-absent 

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent

VITALS at admission

Bp - 100/70 mm hg

PR - 160 bpm

RR -30 com

SpO2 -92% 

GRBS - 150 mg/ dl

SYSTEMIC EXAMINATION

CVS- S1, S2 heard

RS- BAE present and Bilateral crypts present

CNS - intact

PA- Soft , non tender 

INVESTIGATIONS

DAY 1 ADMISSION

DAY 2 OF ADMISSION

PROVISIONAL DIAGNOSIS 

ANTERIOR WALL MI 

TREATMENT

1) INJ HEPARIN 5000 IU IV/ QID

2) INJ PAN 40 mg IV / OD

3) INJ ZOFER 4 mg IV / OD

4)INJ OPTINEURON 1 amp in 100 ml NS 

IV/OD

5)TAB ECOSPRIN AV (75/20) PO/HS

6)TAB CLOPIDOGREL 75 mg PO/ HS

7)TAB MUCOMIX 550 mg PO/OD

8)MONITOR VITALS AND GRBS