A 80 year old male with sob since 4 months and pain abdomen since 3 months

 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 


I've 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 a diagnosis and treatment plan.

CHEIF COMPLAINTS- sob since 4 months and pain abdomen since 3 months

HOPI- Patient was aparently asymptomatic 3 months ago then he developed shortness of breath,insidious in onset,gradually progressive and progressed from grade 2 to 3,orthopnea present and no pnd, no diurnal variation ,no seasonal variations.

Pain abdomen since 3 months in epigastric region radiating to chest ,no h/o variation of pain with food and water intake.

No h/o fever ,cough,cold,vomitings.


PAST HISTORY- He is not a k/c/o DM,HTN,TB,CVA,ASTHMA,EPILESY,CAD,THYROID DISORDERS.

 

PERSONAL HISTORY- 

Appettite- normal

Sleep-adequate

Bowel movemnts- constipation present[once in every 4 days]

bladder movemnts- burning micturition present

Alcohol-occasional 

No smoking and other drug abuse

No known allergies


O/E-

patient is c/c/c and well oriented to time place and person

Bp-110/50,

Pr-68bpm

Rr-22cpm

Temp-97.7F

Spo2-97@RA

Grbs-144 mg%



SYSTEMIC EXAMINATION-

CVS-S1 S2 heard, no thrills and no murmurs

RS-bae+,trachea central,nvbs,no adventitious sound

P/A-soft,non tender

CNS-conscious,no focal deficit









Provisional diagnosis-? heart failur with mid range ejection fraction ?copd


Treatment-

T.DERIPHYLLINE 150 MG PO/BD

NEB.ASTHALIN 1 AMP PN/TID

T SHELCAL 500 MG PO/OD

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