77 year old male with SOB

 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 THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

A 77 year old male, fruit vendor by occupation came to opd with chief complaints of shortness of breath since one week.

HOPI : Patient was apparently asymptomatic two years ago then he developed bilateral knee pain for which he went to the hospital and incidently diagnosed with hypertension. After which he was started on antihypertensives which he did not use regularly. Two months ago patient developed shortness of breath which was insidious in onset and gradually progressive as dyspnea appeared on doing  minor physical activity and progressed to SOB on walking for small distances( Grade 2 to Grade 3) associated with chest pain ,which was intermittent, which was characteristically dragging type and non radiating (no postural and diurnal variation).No aggravating or relieving factors. 

Since one week the patient developed SOB even at rest sometimes associated with chest pain ( characteristics: dragging type and non radiating). No h/o fever, nausea , vomiting, excessive sweating and palpitations associated with chest pain.

PAST HISTORY : 

Known case of Hypertension since 2 years.No h/o diabetes, asthma, TB, epilepsy and thyroid abnormalities. 

No h/o drug allergy and surgeries in the past.

FAMILY HISTORY: No similar complaints in the family.

PERSONAL HISTORY: 

Diet : mixed

Appetite: normal

Sleep: adequate 

Bowel and bladder : regular 

Addictions: none 

GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative, well oriented to time, place and person. Moderately built and nourished.

Pallor: present 

Icterus : absent 

Cyanosis: absent 

Clubbing :  absent 

Lymphadenopathy: absent 

Edema : present

Yesterday : 

VITALS: 

Pulse rate : 84bpm

Blood pressure : 130/80 mm hg

Respiratory rate : 22 cpm

Temperature: afebrile 

SYSTEMIC EXAMINATION: 

Respiratory system: 

Bilateral air entry present.

On auscultation:

End expiratory wheeze and crepts present in infraaxillary area and inter scapula area ( left more than right). 

But wheeze and crepts decreased compared to the day of admission.

 

Cardiovascular system:

S1 and S2 +, apex beat in the 5th intercoastal space in the midclavicular line. No murmurs heard.

#JVP appreciated on the day of admission.

Per Abdomen-

Inspection-

Abdomen - Flat

No abdominal distension

Umbilicus is central

No engorged veins seen

No visible pulsations

Palpation-

Abdomen is soft , Non tender with no Hepatosplemomegaly.

Auscultation-

Bowel sounds heard 

CNS:

 No focal neurological deficits

Provisional diagnosis: Right Heart failure due to cor pulmonale.

Investigations: 

                        HAEMOGRAM:

SERUM ELECTROLYTES:

CUE:

                               

                          SERUM CREATININE:

                           BLOOD UREA:

                                    ECG:

                                2D ECHO: 

                           CHEST X RAY 

TREATMENT : 

T.dytor/po/od -5 days

Nebuliser a/W Duolin 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