77yr old male with chest pain and SOB
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
CASE
A 77 years old male ,fruit vendor by occupation came to the OPD with a cheif complaints of
chest pain since 2 months
Breathlessness since 2 months
History of presenting illness
The patient was apparently asymptomatic 7 years ago Then he developed burning sensation in the chest and went to hospital and diagnosed with some GI disease.
5 years back the patient underwent cataract surgery in the right eye
2 years back patient developed bilateral knee pain for which he was diagnosed with osteoarthritis and then he was also diagnosed with hypertension and he was on medication for few days Then he stopped taking medication and neglected.
Since 2 months the patient developed left sided chest pain which is intermittent in nature . which dragging type,non radiating .
Shortness of breath since 2 months ,which was insidious onset and progressive in nature where the patient used to get SOB on doing small work later he used to get sob on walking for small distance(grade 2 to grade 3). Form the last 7 days he is getting Breathlessness on sitting/resting(Grade 3 to grade 4) not associated with cold and cough ,no postural and diurnal variation ,seasonal variation
No History of PND
No History of palpitations
No History of excessive sweating
Past History
No History of similar complaints in the past
Known History of hypertension since 2 years and he is not on regular medication
No History of diabetes, asthama,Tuberculosis and Epilepsy
Family history
Not significant
Personal history
Diet-mixed
Normal appatite
Regular Bowel and Bladder movement
Sleep is adequate
No history of drug allergy
No history of addiction
General examination
The patient is conscious, coherent and cooperative. Well oriented with time place and person. Moderately nourished and moderately built
Vitals
Pulse rate-84bpm
Bp-140/100mm of Hg
Spo2-96%
Temp-afebrile on touch
Respiratory rate-18 bpm
B/L pedal edema is seen(pitting type)
No pallor, icterus, cyanosis ,clubbing and lymphadenopathy
Systamic examination
Cvs-Apex beat is felt at left 5th intercostal space,s1 and s2 heard
Respiratory system-crepts present
B/L air entry is present,
end expiration wheeze ,
Per abdomen examination-
Abdomen is falt
Soft and non tender
No organomegaly
Bowel sounds are heard
CNS-no focal neurological deficits
TREATMENT
T.dytor/po/od -5 days
Nebuliser a/W Dulin and Budecort 12th hourly
Salt restriction/2g /day
T.Telma 40 mg po /od in the morning
Lasix 40 mg iv twice a day
Hydrocort inj 100mg iv
BP monitoring 4th hourly
Provisional diagnosis
Chest pain under evaluation
Cor pulmonale??
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