A case of 86 year old male with shortness of breath and fever

 M. Naga Varsha 

Rollno. 76

Admission no. 176015

9th semester 


This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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 diagnosis .


Following is the view of my case..


A 86 year old male came to the casuality on 18/10/2021 with chief compliants of 

1. Shortness of breath and orthopnea since 4days 

2. Fever since a day 



HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10 years back and then he had a prick on his left foot which gradually developed swelling over the limb associated with fever was taken to local RMP and was told he had infection. In our hospital it was diagnosed as a non healing ulcer and after a week he was taken to a hospital in Hyderabad for further evaluation and grafting was done and it was unsuccessful and since then he gets dressing for the ulcer daily till date. There is a history of ulcer getting infected frequently.

2 years ago - Patient had SOB of grade 3, cough and orthopnea and was taken to a hospital and was diagnosed to have a heart failure. Since then he is on regular medication.

2 months ago-  patient developed infection in the ulcer and edema over the body and was taken to hospital and was told that he had infection in whole body nd was admitted and treated for 5 days. As he couldn’t take many medications he stopped taking heart failure medicines. 

 After 1-2 months of stoppage of medication patient developed SOB 4 days back which was grade 4 . Pateint had taken nebulization since four days in night due to increase sob at night.it was associated with orthopnea . Since a day patient complained of fever which was high grade.


PAST HISTORY 

No history of  DM , HTN, EPILEPSY,TB 


PERSONAL HISTORY: 

Diet : mixed 

Appetite : decreased

Sleep: disturbed due to orthopnea 

Bowel and bladder : regular 



GENERAL EXAMINATION:

Pt. is consicous , cooperative and oriented to time place person 

Thin built , moderately nourished 

Pallor present 

No icterus, cyanosis , clubbing , lymphadenopathy , edema 










Vitals: 

BP: 140/80mmhg

PR : 121 beats per min 

RR: 21cycles per min 

SPO2-  87 % at room air 

GRBS - 149mgd%


SYSTEMIC EXAMINATION: 


Cardiovascular system:

Inspection:

- Shape of the chest normal

- Trachea appears to be central

- No apex beat

- No engorged veins or pulsations 

- No visible parasternal heave

RAISED JVP NOTICED 

Palpation:

All inspection findings confirmed

Trachea is Central

Apex beat felt at 6th intercoastal space lateral to midline of clavicle 

No parasternal heave 

All peripheral pulses felt 

Auscultation:

S1 S2 not much appreciated..heard very low 

No murmurs 



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