Prefinal case- 83 yr old male with shortness of breath with pneumonia

 

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I have been given this case 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.

A 83yr old male came with complaints of  shortness of breath since 17 days.

chief  complaints:

 cough since 20 days

Fever since 19 days

shortness of breath since 17 days

History of Presenting illness:

Patient was admitted to ICU on 20/11/23 in the morning at 10 am with  breathlessness. It was insidious in onset and gradually progressive, continuous and present during rest ( patient  was feeling breathless even upon walking to washroom) with no associated relieving factors. Patient's attender also complained of awakening during night due to breathlessness. No h/o palpitations, stridor, or hoarseness of voice 

Patients attender also told about cough which was insidious in onset, gradually progressive associated with sputum which was white in colour ,scanty  amount, mucoid in consistency and non foul smelling

 Patient also complained of intermittent spikes of fever  since 19 days( 4 times a day ), associated with chills and rigors, not relieved on taking medication and not associated with headache, vomiting

 No h/o chest pain, orthopnea,

No h/o recurrent sore throat or cold

No h/o loss of consciousness, 

PAST HISTORY:

No history of similar complaints in the past

Patient is N/K/C/O of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders

No h/o blood transfusions and surgeries

FAMILY HISTORY: Insignificant

PERSONAL HISTORY:

as mentioned by the attender

Diet - Mixed 

Appetite - decreased

Sleep- Adequate

Bowel and Bladder movements- Regular

Addiction - consumption of alcohol occasionally,

      h/o smoking since 30 yrs (3 packs per day) reduced to 1 pack per day since 2 yrs

GENERAL EXAMINATION :

Patient is conscious, coherent and cooperative and well oriented to time, place and person

He is moderately built.

Pallor- present 

Pedal edema-present up to knee

No cyanosis,clubbing,lymphadenopathy.

Vitals : 

Temp - afebrile

BP - 120/70 mm hg  measured on Left upper arm in supine position

Pulse rate - 120bpm , regular rhythm , normal character, high volume, no radio-radial and no radio-femoral delay

RR- 27cpm

SYSTEMIC EXAMINATION :

 RESPIRATORY SYSTEM :

Upper respiratory tract :

Nose : no abnirmality detected

Oral cavity : whitish plaques  like lesions distributed over  the oral mucosa ( Oral candidiasis ?)

Examination of chest proper :

Inspection : 

1. Shape of chest - elliptical

2.  Trachea position-appears to be in central

3. Apical impulse - not seen

4. Movements of chest : abdominothoracic type of respiration, with indrawing of intercostal space.

5. Skin over chest : no redness ,engorged veins ,sinuses ,nodules ,scars and swellings.

6 . Abdominal quadrants moving equally with respiration

Palpation :

All inspectory findings are confirmed.

No local rise of temperature and tenderness 

Percussion :  Dull note  in basal region

 Auscultation :

1. Breath sounds- right side crepitations heard , prominent near basal region  of lung and in infra axillary region- ( like water bubbles ?)

    left side normal breath sounds

2. No other abnormal sounds heard

On admission - chest xray showing bilateral infiltrates with consolidation

After he developed ARDS

CVS: S1, S2 heard , no murmurs 

CNS: No facial asymmetry. 

         No focal neurological abnormality detected

P/A : scaphoid, soft, non tender, bowel sounds heard and no organomegaly 

                                 On Admission :

Referral to psychiatry

Reports to have slept last night with sleep disturbance , 3times awakening due to SOB

Reports craving for tobacco

Rx- Tab olanzapine, clonazepam, nicotine gums

Provisional diagnosis: ARDS

? Community acquired pneumonia- E.Coli

Tobacco and alcohol dependance syndrome

Lab investigations: 

Treatment  :

Advised -candid mouth plant l/A bd -2 weeks

Betadine gargle-3 times in a day

Treatment given:

•  DNS,RL @75ml /hr
• Inj.piptaz 4.5g iv 8 hrly
• Tab.levofloxacin 750 mg po/od
• Tab.bactrim-ds 800/160 po/bd
• Cap.flucanazole 200mg po/od
• Cap.doxycycline 100 mg po/bd
• Inj pan 40 mg iv/od
• Inj.neurobion forte 1 amp in 1000 ml ns
• Syp.grillinctus 15ml po/tid
• Neb.ipravent-8th hrly
• Budecort-12th hrly
• Tab-dolo 650mg po/tid