A 85 year old male patient came with the complaints of shortness of breath since 2 days

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

A 85 year old male patient came with the complaints of shortness of breath since 2 days

Complaints of shortness of breath since 2 days 

morning.

Complaints of bloating since yesterday 

Complaints of decreased urine output since Morning.

HISTORY OF PRESENTING ILLNESS:- 

Patient was apparently asymptomatic 2 days back then developed difficulty in breathing which is insidious in onset gradually progressive 

H/O PND, orthopnea present 

H/o pedal edema present 

H/o abdominal distension present 

No H/o fever with pain, sore throat 

No H/o involuntary movement

NoH/o skin manifestations like rash, nodules

 No H/o Recurrent respiratory infection
Syncope

No H/o Hemoptysis

No History of chest pain ; palpitations; loss of consciousness 

PAST HISTORY:- 

No similar complaints in the past 

Not a known case of DM ;HTN; CAD; CVA ; Thyroid ; TB ; asthma epilepsy .

Personal history:- 

Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- decreased 

Addictions :- chronic smoker of chutta which he stopped 6 years back due to complaint of hemoptysis which was investigated?? And found no pathology !

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

At the time of examination :- 7/9/23

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY 

EDEMA PRESENT 

TEMPERATURE:- AFEBRILE

PR:110bpm

BP:140/80mmHg

RR:32cpm

SYSTEMIC EXAMINATION:- 

RESPIRATORY SYSTEM:- 

RESPIRATORY SYSTEM:-

INSPECTION:- Chest appears symmetric

    No Dilated veins, scars, sinuses

INSPECTION:

1. Shape of Chest - normal

2. Trachea position central

3. Apical Impulse - no visible

4. Movements of the chest: Respiratory rate:- 34cpm .

5. Skin over the chest: NO engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.

6. All the areas appear normal.

PALPATION:

1. No local rise in Temperature and tenderness

2. All inspector findings confirmed. (Tracheal position, apex beat)

3. Expansion of the chest- equal in all planes 

PERCUSSION:

Resonant all over the chest except infraxillary area and infrascapular area .

AUSCULTATION:

1. Normal breath sounds were heard in all areas except IAA AND ISA . 

Crepts are heard in IAA And ISA .

CVS EXAMINATION:- 

S1 S 2 heard  ; NO MURMURS 

PER ABDOMEN:- 

no tenderness

no palpable organs

bowel sounds - present

CNS EXAMINATION:- 

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

INVESTIGATIONS:- 

On the day of admission 6/9/23:- 

Serology:- NEGATIVE 

RBS - 134 mg/dl

B.urea - 53 mg/dl

S.Cr - 2.4 mg/dl

Na - 140 mEq/L

K - 4.3mEq/L

Cl- 103mEq/L

CUE -

Albumin  ++++

Sugar - Nil

Pus cells - 8-9 cells

Epi cells - 2-3 cells 

RBC :- 10-12 cells 

Hb- 13.0

TLC - 18,000

MCV - 92

MCH - 30.7

МCHC  - 34.0

PLT - 2.56 LAKHS 

7/9/23 :- 

Hb:- 13.5

TLC :- 20,500

PLT :- 2.6 lakhs 

ECG ON 6/9/23 :- 

On 7/9/23 :- 

CXR :- 

DIAGNOSIS:- ACUTE EXACERBATION OF COPD WITH ACUTE COR PULMONALE WITH DE NOVO DM II AND HTN .

TREATMENT:-

1. INJ LASIX 40 mg IV/BD IF SDP >110mmHg
2. INJ AUGMENTIN 1.2 gm IV/BD
3. Intermittent Bipap
4. TAB AZITHROMYCIN 500 mg PO/OD
5. INJ HYDROCORT 100 mg IV/TID
6. Inj aminophylline 500 mg IV / SOS
7. INJ HAI S/C TID ( inform Grbs)
8. Salt restriction < 2g / day; fluid restriction < 1.5 
9. Nebulisation with budecort; mucomist 
10. Inj N ACETYL CYSTEINE 400mg IV / SOS 
11. TAB ECOSPIRIN AV 75/10 Po/HS 

Date :- 8/7/23 

INVESTIGATIONS:- TROP I :- 9,693 

Hb :- 13.3 

TLC :- 24,500 

PLT :- 2.3 

Sr  CREAT :- 2.9 

SOAP NOTES 

08-09-2023:

ICU BED1

S:

Bloating of stomach

Shortness of breath grade 3

O:

I/o - 1000/1400 ml

Bp- 140/90 mmhg

Pr - 103 bpm

Rr- 24 cpm

Spo2 - 99% at 4L O2

Grbs - 183

CVS - S1 S2 + No murmurs

RS - BAE+ ,B/l wheeze+ ,crepts+ in Rt IAA and Rt ISA

P/A - Soft and NT

CNS - NFND HMF+

A:

DIAGNOSIS:- 

HF with reduced EF(EF=30%) secondary to CAD (NSTEMI )with acute exacerbation of COPD with type 1 Resp Failure with Acute Cor pulmonale with AKI (renal) with denovo DM 2 and HTN

P:

1.Inj Heparin 5000Us/c TID

2.INJ LASIX infusion 10 mg/hr

3.Intermittent Bipap

4.INJ HYDROCORT 100 mg IV/TID

5.Inj aminophylline 500 mg IV / BD

6.INJ HAI S/C TID ( inform Grbs)

7.Inj MgSo4 1gm IV/OD

8.Nebulisation with budecort; mucomist

9.Inj N ACETYL CYSTEINE 400mg IV / BD

10.Tab Ecosprin AV (75/10) PO/HS

11.Tab Met - XL 25 mg PO/OD

12.GRBS 7 point profile