60 yr old male with SOB

A 60 years 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 


A 60 year old Male came (on 18/10/22)with 

c/o cough since 6 days 

C/o SOB since 6 days 


HOPI- 

Pt was apparently asymptomatic 1 year back Then he had fever with thrombocytopenia,from then he started having SOB ,was admitted in hospital and got treated 

Now after 1 year pt complaints of 

Cough with sputum which is white in color ,mucoid,non foul smelling,non blood stained 

Cough is more during night 

C/o SOB since 3 months 

SOB increases on lying down 

Grade-

Palpitations +

Sweating +

A/w fever 

Past history:

N/k/c/o HTN,DM,Asthma,Epilepsy ,TB

H/o surgery to spine


Personal history :

Diet mixed 

Appetite normal 

Bowel and bladder movements regular 

Sleep disturbed (because of cough)

Smokes 9 beedis per day (since 50 years)

Smokes cigarette occasionally 

Drinks toddy in summers

Drinks alcohol occasionally 


Daily routine-


General examination 

Pt is c/c/c well oriented to time ,place and person 

Well built and nourished 

No pallor,icterus ,clubbing ,generalised lymphadenopathy 

Vitals on admission -

BP-170/60mmHg

PR-50bpm

RR-32 cpm




CVS-

S1S2 +

Pan systolic murmur 

JVP elevated


RS -

Inspection -

Trachea appears to be central 

 Pattern of breathing -abdominal 

Shape of chest -barrel 

Auscultation-wheeze +

CNS:higher motor functions intact 

No focal neurological deficit 

Investigations:

Serology-negative

FBS-78 mg/dL

PLBS-108 mg/dL

Blood urea -31 

Serum creatinine-1.0

Hb-11.2 gm/dL

TLC-6,700 

Neutrophils-57

Lymphocytes-33

Eosinophils -1

Monocytes-9

Basophils-0

TP-5.9

Albumin -3.83

A/G-1.85

FBS-78

PLBS-108


HbA1c-6.4


Cxray-

18-10-22

PFT



Diagnosis:


COPD (chronic bronchitis >emphysema ) with right heart failure 


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