Case of 63 year old male with shortness of breath

  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 a series of inputs from an 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 centered online learning portfolio and your valuable inputs in the comment box is welcome.

Neha Tipparaju 

9th Semester, Roll no. 100 

Case of 63 year old male with shortness of breath 

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

All the information was obtained from the patient's relative, under the guidance of Dr. Rakesh Biswas sir.

63 year old male patient, farmer by occupation and a resident of Nalgonda, came with chief complaints of:

Shortness of breath since 10 days
Cough with sputum since 10 days
Chest pain since 10 days
Fever since 2 days

Timeline of events:

25 years back: Patient had complaints of joint pain.
Started with Right wrist, then spread to Right elbow ---> Left wrist ---> Left elbow ---> Cervical joint ---> Bilateral Distal interphalangeal joint ----> Bilateral Proximal interphalangeal joint ----> Bilateral knee joint ----> Bilateral ankle joint
The pain increased during the morning and relieved on 10 minutes of activity

On consulting a local RMP, he started taking NSAIDs and steroids

10 years back:  He had a fall from bike, but sustained no injuries.

2 years back: He had an episode of Hematemesis. Received 2 blood transfusions. Also diagnosed as Iatrogenic Cushings Disease

1 year back: Abdominal distension and pedal edema. Relieved on medication.

7 months back: Trauma to Left Leg forming an ulcer. Culture showed Pseudomonas. Dressing was done.

Presently,  Complaining of Shortness of breath even on walking (MMRC Grade 3) Orthopnea and PND is present

Personal history: Has been smoking 1 pack beedi per day for 40 years

ON EXAMINATION:-

On presentation : Patient is conscious, coherent and cooperative and examined in a well lit room.

He is an obese individual with flexion at the PIP joints of his both right and left hand and even toe fingers

 Healed ulcer present on his left leg

Vitals - 

PR - 89 bpm

Bp - 130/80mmhg

RR - 25cpm

Spo2 - maintaining at 89 % on Room air 

Afebrile 

No raised JVP

Cvs - 

Apex beat at 6th ICS at MCL S1,S2+

Lungs -

Barrel shaped chest is seen

Movements are symmetrical

Trachea is central

Bilateral inspiratory crepts in all Lung fields 

Expiratory wheeze in bilateral IAA,ISA

Per Abdomen- 

Distended

Non tender

Bowel sounds +

CNS - NAD 

We got his 2decho done showed EF 30% with global hypokinesia and dilated LA and LV

Distended abdomen is seen

However, umbilical was inverted and no fluid thrill was present, therefore indicating truncal obesity

Investigations:

Diagnosis - 

1.HFREF with EF 30%

2. ? Acute exacerbation of COPD

3. Iatrogenic cushings syndrome

4. Rheumatoid arthritis with eczematous Cutaneous lesions

5. ? Hansen's disease

TREATMENT:-

02/11/21

1) NEB WITH DUOLIN--8TH HOURLY

                      BUDECORT--12TH HOURLY

2) TAB.PREDISOLONE 15 MG PO/OD

D1 3)TAB.AUGMENTIN 625 MG PO/BD

4) SYP. ASCORYL 10 ML PO/BD

5) TAB. ULTRACET 1/2 tab QID

6) TAB. PCM 500 MG PO/TID

7) MONITOR VITALS 4th HOURLY

8) REVIEW SOS

9) INJ. LASIX 40 MG IV/BD

10) TAB. ECOSPIRIN AV (75/20) MG PO/HS

11) TAB.TELMA 40 MG PO/OD

03/11/21

C/o 1) SOB REDUCED

        2) CHEST PAIN+

Treatment:-

1) NEB WITH DUOLIN--8TH HOURLY

                      BUDECORT--12TH HOURLY

2) TAB.PREDISOLONE 15 MG PO/OD

D2 3)Inj.AUGMENTIN 1.2 Gm IV/BD

4) SYP. ASCORYL 10 ML PO/BD

5) TAB. ULTRACET 1/2 tab QID

6) TAB. PCM 500 MG PO/TID

7) MONITOR VITALS 4th HOURLY

8) REVIEW SOS

9) INJ. LASIX 40 MG IV/BD

10) TAB. ECOSPIRIN AV (75/20) MG PO/OD

11) TAB. ALDACTONE 25 MG PO/OD

12) BIPAP INTERMITTENTLY

13) INJ. HYDROCORTISONE 100 MG IV/OD

14) SYP. DUPHALAC 20 ML HS

04/11/21

C/O 1) CHEST PAIN ON COUGHING

        2) CONSTIPATION SONCE 4DAYS

TREATMENT

1) NEB WITH DUOLIN--1resp INH 6THHOURLY

                      BUDECORT--1 RESP INH 8TH HOURLY

2) TAB.PREDISOLONE 15 MG PO/OD

D3 3)Inj.AUGMENTIN 1.2 Gm IV/BD

4) SYP. ASCORYL 10 ML PO/BD

5) TAB. ULTRACET 1/2 tab QID

6) TAB. PCM 500 MG PO/TID

7) MONITOR VITALS 4th HOURLY

8) REVIEW SOS

9) INJ. LASIX 40 MG IV/BD

10) TAB. ECOSPIRIN AV (75/20) MG PO/OD

11) TAB. ALDACTONE 25 MG PO/OD

12) BIPAP INTERMITTENTLY

13) INJ. HYDROCORTISONE 100 MG IV/OD

14) SYP. DUPHALAC 15ML PO/OD

15) INJ.PANTOP 40MG IV /OD

05/11/21

Date-08/11/2021

SOAP notes 

S- SOB reduced

O-

Pt is c/c/c

BP-130/70 mm hg

PR-114 bpm

RR-22 cpm

GRBS-106

SPO2:96% on room air

CVS: S1 S2+

RS: BAE+, B/L diffuse rhochi +

P/A: soft, non tender 

A-

HFrEF -EF 30%

With acute exacerbation of COPD

With k/c/o Iatrogenic cushings syndrome

? RA vasculitis

? Hansens disease

P-

 D3 --T.AZITHROMYCIN 500 MG OD

TAB. LASIX 40MG IV BD

TAB. PANTOP 40mg IV OD

D7--INJ. AUGMENTIN 1.25 GM IV BD

NEB DUOLIN 1 RESP INH P/N BD

NEB BUDECORT 1 RESP P/N BD

T. PREDNISOLONE 15MG PO OD

T.ULTRACET 1/2 TAB QID

T. ECOSPIRIN AV (75/20) MG PO OD

T ALDACTONE 25MG PO OD

T PCM 650 MG PO SOS

SYP ASCORIL 10ML PO TID

SYP DUPHALAC 15ML PO BD

LIQUID PARAFFIN FOR L/A BD

FUCIDIC CREAM FOR L/A BD

BO, PR, SPO2,TEMP, CHARTING 4TH HRLY

GRBS 12TH HRLY

BIPAP INTERMITTENTLY

--4TH HOURLY

Patient was discharged on 10th November, after being advised nebulization at home.