67 yr old gentlemen with SOB and fever

Name : Nikitha .P

Roll Number : 102

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. 

UNIT 1 

AMC CUBICAL 2

DOA:04/06/23

A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of 

Shortness of breath since 1 week 

Fever since 4-5 days

Burning micturition since 4 days

HOPI :

Pateint was asymptomatic  10 yearsback then he developed

Pain during micturation insidious in onset gradually progressive  on a certain occasion he had a beer(750ml) & while micturating he noticed pressure pushing out some stone later which his pain diappeared

8 years back then he developed difficultly /Pain during walking(left knee pain followed by right knee)  (used painkillers) ,following which he visited a hospital at miryalguda and  treated with each intraarticular steroidal injections every year for which he observed decrease in knee pain 

6 years ago again he had pain during micturation ,visited Gandhi hospital wassail diagnosed with renal caliculi. For which he was on medication 

3 months back he developed abdominal pain  loin to groin type sudden onset there was increase pain and burning sensation during micturation  -->visited miryalaguda hospital -->renal stenting

H/o Decresed renal ouput since 6 months 

15 days back his abdominal worsened , on &off left lumbar pain devleoped on eating non veg at a party 

 1 week ago he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital.

He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again.

C/o pain abdomen on &off left lumbar region since one week

C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents

C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling

C/o decrease in appetite since 1 week 

No c/o of chest pain , palpitations 

PSYCHO-SOCIAL COMPONENT :

 Inputs,Obtained from his elder son - Most active (39YR OLD, who is a business man by Occupation(owns a small hotel at TTD tirupathi) , Educated speaks Hindi ,Telugu , Understands some words in English and Speaks some words also  he  said Thank You(English ) to me after Conversation) ,and Cheerful man  who always keep smiling ,Loved speaking with her (felt happy) 

67YR Old Male Patient barber by occupation,resident of miryalaguda 

He stayed at mirayalguda, along with his family Since very young age , Built their Own small House at their place in 1980s and was not registered. Family type -joint family (7 members) 

He studied up to 4thstandard knows to do signature. He was married 40 years ago  non consangenous

Wife  58 years old (Daily wage labourer) 

Patient mother died 20yrs ago ND has two siblings - (elder sister lives happily with her family in miryalguda) , younger brother died 15yrs ago with gastric carcinoma. #

 He has 2 Children : 

1st Child - son 39 YR Old married 20 years ago  now has 2 Children(daughter-studying 12 th standard, son -8th class)  ,Stays in Tirupathi .

2nd child -35 yrs old unmarried works at diamond testing lab. 

Daily routine : wake up at 7am--->freshup have medications for hypertension and around 8am he has his breakfast usually curd rice  he is a barber who loves his work,goes to his shop by walk (around 30mins) comes to his home for lunch and goes back to his work around 6:30pm he comes back to his home have a shower and watches tv --->completes his dinner by 9pm --->goes to bed by 10pm 

After he developed B/L knee pain he reduced his work time after lunch he wouldn't go to work. 

Maintains Personal Hygeine and Cleanliness to extreme end -His clothes should be very neat ,shaves his beard every 2 times in a week ,takes bath regularly for 30-40mints , sometimes he washes his own clothes despite of his knee pain .No Personal and  Professional stressors present

whatever may be his health condition --- He is a happy going ,Cheerful person , who always speaks with love to everyone ,even with strangers 

PAST HISTORY

He had history of hypertension since 10 years and on  medication 

TAB Olmesartan -H

No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 

History of previous surgery Renal stunting 6 months back

PERSONEL HISTORY: 

Diet:mixed

Sleep:regular 

Appetite: decreased appetite since 1 month 

Bladder - decreased urine output with burning micturation since 1 month

Bowel movements are regular 

Addictions:he started taking chewable tobacco since 30 years and stopped one week back

He also had a history of taking alcohol since 25 years and stopped one year back

He started smoking (1beedi pack daily) 30 yrs ago later stopped smoking 22 yew ago because of his elder son 

Family history: Not significant

Treatment history: 

Renal Stenting 6 months back

General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

Pallor present 



Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 







VITALS:

TEMP:97.2F

PR:117bpm

RR:28cpm

BP:120/80

Spo2: 94% @4L 02

GRBS:128mg/dl

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & barrel in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-







All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (NVBS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)

AP diameter- 28cms,transverse diameter- 28cms

Percussion:  resonant-normal.

Auscultation:normal vesicular breath sounds with no added sounds

Vocal resonance normal.

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs

PER ABDOMEN





**Shape of abdomen-scaphoid

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - Not palpable

**Bowel sounds - Normal

Provisional Diagnosis: 

Urinary tract infection 

Investigations:































Final diagnosis:

Urinary tract infection

Post renal  aki secondary to left ureteric obstruction -?mass/strictures

K/c/o htn since 10 years

Normocytic normochromic anemia 

Kyphosis 

Treatment:

1.INJ LASIX 40 MG IV STAT

2.NEB WITH DUOLIN STAT  BUDECORT

3.INJ NEOMOL 1GM IV SOS

4.TAB DOLO 650MG PO/BD

5.TAB OLMESARTAN-H PO/BD

6.BP,PR,TEMP CHARTING 4TH HOURLY.

5/6/23

Vitals:—

Temperature : Afebrile

Pulse rate : 94 bpm

Blood pressure: 120/80 mn Hg

Treatment:-

1.Inj neomol 1g IV Sos

2.tab dolo 650 mg  BD

3.tab olmesartan 

4. Neb c duolin /budecort

5.tab pan 40 

6.syp alkaprose B6 5ml

6/6/23

Vitals:-

Temperature : Afebrile

Pulse rate : 84 bpm

Blood pressure: 110/80 mn Hg

Treatment:-

1.Inj neomol 1g IV Sos

2.tab dolo 650 mg  BD

3.tab olmesartan 

4. Neb c duolin /budecort

5.tab pan 40 

6.syp alkaprose B6 5ml

7. Syp cremaffin 10ml 

8.tab tamsulosin 0.4 mg

7/6/23

Vitals:-

Temperature : Afebrile

Pulse rate : 76 bpm

Blood pressure: 110/70 mn Hg

Grbs : 110mg /dl

Treatment:-

1.Inj neomol 1g IV Sos

2.tab dolo 650 mg  BD

3.tab olmesartan 

4. Neb c duolin /budecort

5.tab pan 40 

6.syp alkaprose B6 5ml

7. Syp cremaffin 10ml 

8.tab tamsulosin 0.4 mg

8/6/23

Vitals

Temperature : 99.6 F

Pulse rate : 74 bpm

Blood pressure: 80/50 mm Hg

GRBS : 120mg /dl

Respiratory rate : 20 cpm

Treatment:

1.Inj neomol 1g IV Sos

2.tab dolo 650 mg  BD

3.tab olmesartan 

4. Neb c duolin /budecort

5.tab pan 40 

6.syp alkaprose B6 5ml

7. Syp cremaffin 10ml 

8.tab tamsulosin 0.4 mg

9/6/23

Vitals

Temperature : 98.1F

Pulse rate : 78 bpm

Blood pressure: 110/80 mm Hg

GRBS : 120mg /dl

Respiratory rate : 19 cpm

Treatment:-

1.inj piptaz 2.2sqm IV 

2. IV fluid NS 75ml/hr

3.Inj neomol 1g IV Sos

4.tab dolo 650 mg  BD

5.tab olmesartan 

6.Neb c duolin /budecort

7.tab pan 40 

8.syp alkaprose B6 5ml

9.Syp cremaffin 10ml 

10.tab tamsulosin 0.4 mg

10/6/23

Vitals

Temperature : 101 F

Pulse rate : 96 bpm

Blood pressure: 120/70mm Hg

Treatment:-

1.inj piptaz 2.2sqm IV 

2. IV fluid NS 75ml/hr

3.Inj neomol 1g IV Sos

4.tab dolo 650 mg  BD

5.tab olmesartan 

6.Neb c duolin /budecort

7.tab pan 40 

8.syp alkaprose B6 5ml

9.Syp cremaffin 10ml 

10.tab tamsulosin 0.4 mg

11/6/23

Vitals:-

Temperature : 101 F

Pulse rate : 96 bpm

Blood pressure: 120/70mm Hg

Treatment:-

1.inj piptaz 2.2sqm IV 

2. IV fluid NS 75ml/hr

3.Inj neomol 1g IV Sos

4.tab dolo 650 mg  BD

5.tab olmesartan 

6.Neb c duolin /budecort

7.tab pan 40 

8.syp alkaprose B6 5ml

9.Syp cremaffin 10ml 

10.tab tamsulosin 0.4 mg

12/6/23

Treatment:-

1.inj piptaz 2.2sqm IV 

2. IV fluid NS 75ml/hr

3.Inj neomol 1g IV Sos

4.tab dolo 650 mg  BD

5.tab olmesartan 

6.Neb c duolin /budecort

7.tab pan 40 

8.syp alkaprose B6 5ml

9.Syp cremaffin 10ml 

10.tab tamsulosin 0.4 mg