65 year old male with shortness of breath and uncontrolled sugars.

 This  is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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.

65YEAR OLD MALE BROUGHT TO THE HOSPITAL WITH SHORTNESS OF BREATH

CHIEF COMPLAINTS: 

A 65 year old male patient came with the complaints of shortness of breath for the past 1 week, cough, fever and decreased urine output for the past 3 days. 

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 1 week back when he developed shortness of breath grade 2, which was relieved on taking rest. 

- He then developed cough which was productive in nature, whitish coloured sputum, not associated with blood.

- He has fever since the past 3 days which is high grade, associated with chills and which was insidious in onset, intermittent, high grade, decreasing on taking medications, had no aggravating factors and what evening rise of temperature. 

- He has a history of decreased urine output for the past 3 days.

- No H/O weight loss or loss of appetite since the past 3 days.

- No H/O chest pain, palpitations and sweating 

- No H/O pedal Edema, burning micturition or frothy urine.

Daily routine:

He usually wake up around 6 in the morning,does his daily routine,

PAST HISTORY-

- No similar episodes in the past. 

- Patient is a k/c/o DM type 2 since 1 week and has been put on Glimi M1.

- Not a known case of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD. 

PERSONAL HISTORY- 

Occupation: Agricultural labourer

Diet: Mixed 

Appetite: Normal 

Sleep: Normal 

Bowel and Bladder: Regular

No allergies 

Takes alcohol/toddy occasionally (only on festivals) 

Is a known smoker and usually smokes into 5-6 bidi/day 

 

But he stopped smoking and taking alcohol 3 years ago.

FAMILY HISTORY- 

No similar history in family.

GENERAL EXAMINATION- 

Patient is examined in a well lit room after taking informed consent. 

Patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 

Pallor: Absent 

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Generalized Lymphadenopathy: Absent 

Edema: Absent

Dehydration: Mild 

VITALS

Blood Pressure: 110/70 mmHg

Respiratory Rate: 19 cycles per minute

Pulse: 106 bpm

GRBS- 540mg%

Temperature: Afebrile

SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM-  

Inspection:

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Palpation:

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion:

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation:

Wheeze heard in Bilateral infrascapular areas.

Abdominal examination:

Inspection 

Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.

Palpation 

 Soft, non tender, no organo megaly.

Auscultation 

Bowel sounds heard

 

Cardio vascular Examination:

No visible pulsations, scars, engorged veins. No rise in jvp 

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

CNS examination: No neurological deficit found.

Gait: normal.

INVESTIGATIONS: 

HEMOGRAM

Hemoglobin: 12.1

TLC: 20,500

Platelet: 1.99

PCV: 34.8

ELECTROLYTES

Na: 129mEq/L

Cl: 98 mEq/L

K: 3.4 mEq/L

RENAL FUNCTION TESTS

Urea: 38

Creatinine: 1.0

LIVER FUNCTION TESTS

Total Bilirubin: 0.63

Direct Bilirubin: 0.20

SGPT: 15

SGOT: 40

ALP: 494

Total Protein: 5.7

Albumin: 2.6

A/G: 0.86

30/12/22

HEMOGRAM

Hemoglobin: 12.5

TLC: 15,100

Platelet: 2.23

PCV: 36.5

ELECTROLYTES

Na: 131 mEq/L

Cl: 98 mEq/L

K: 3.5 mEq/L

RENAL FUNCTION TESTS

Urea: 61

Creatinine: 1.2

ECG 

Chest X Ray 

Colour Doppler 

Ultrasound

PROVISIONAL DIAGNOSIS:

Acute exacerbation of COPD with left upper lobe consolidation with cavitations (?infective) with uncontrolled sugars

Denovo DM detected 5 days back .