77yr 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 .

Rollno.61

Aruna.J

A 77 yr old male fruit vendor by occupation came with  Chief Complaints of  SOB and since 1 week .

He was apparently asymptomatic 2years back. He went to the hospital with complaints of B/L knee pain diagnosed as Osteoarthritis  along with Hypertension. He was started on medication for Hypertension which he used only occasionally  (Medication unknown). Since 2 months he started developing shortness of breath which was insiduous in onset , gradually progressed as it  appeared on doing any minor physical activity  and progressed to SOB on walking for small distance ( Grade 2 to Grade 3) associated with Chest Pain( On and off) which was dragging  type, non radiating(No postural or  Diurnal variation) no aggravating or releiving factors to the patient.

Recently since last 1 week 

he started to have SOB even at rest associated with Chest pain sometimes which was again dragging type and non radiating .

NO H/O  Nausea , Vomiting ,excessive sweating and Palpitations assc. With chest pain.

 

PAST HISTORY- 

Known case of HTN

No H/O  DM, T.B, Asthma, Epilepsy, &Thyroid Abnormalities or any major surgeries done in the past .

FAMILY HISTORY - No simliar complaints in the family.

PERSONAL HISTORY- 

Diet -Mixed

Appetite- Normal

Bowel and Bladder - Regular

Sleep- Adequate

Addictions-None   

  

General examination-

Patient was conscious,Coherent and co operative. Moderately built and moderately nourished.

Pallor - Present

Icterus - Absent 

Clubbing - Absent

Cyanosis- Absent

Lymphadenopathy- Absent

Pedal Edema - Present (Pitting type)

Vitals-

Temp- Afebrile

RR- 17cpm

Pulse rate- 64bpm

BP- 140/90 mm Hg

Systemic Examination-

Respiratory system-

Chest shape symmetrical

Trachea - Central

Expansion of chest is equal in all directions

Auscultation-

Crepts heard

Wheeze present

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

CVS-

Shape of chest is symmetrical with no scars and sinuses.

 S1 ,S2 heard 

No murmurs heard.

Provisional Diagnosis-

Chest pain under evaluation could be Right heart failure ??

(As pulmonary pressure is more than 25 mm Hg -cor pulmonale

Investigations-

Serum Electrolytes

CUE

ECG:

2D echo

Xray-

TREATMENT 

T.dytor/po/od -5 days

Nebuliser a/W Dulin 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