56 year old male with fever ,shortness of breath,cough ,generalised weakness

  August 31st, 2021

CHENNAMADHAVUNI DIVYA, 8th semester

Roll number-21

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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 and treatment plan.

Following is the view of my case:

Date of admission:-28-8-2021   

Chief complaints :

A 56-year-old male patient has come to the opd with the chief complaints of     

• Fever since 10 days
• Shortness of breath since 5 days
• Cough since 10 days
• Generalized weakness: since 15 days     

History of present illness :

The patient was asymptomatic 15 days back and then he developed,

Generalized weakness, which was insidious in onset and is gradually progressing.

Fever which was insidious in onset, high grade, intermittent in nature and associated with chills, rigours,cold,headache,loss of smell and taste sensations.

He developed shortness of breath which was in stage 2 since 15 days and has progressed to stage 4 since 5 days ,which was insidious in onset and gradually progressing 

He has had productive cough which is mucoid in consistency, small in quantity,non-foulsmelling and non-blood stained.

Associated with pain.

He has had body pains and joint pains for a year

Dragging type of pain in his shoulders, back, arms and legs.

Not associated with pedal oedema, facial puffiness, palpitations, decreased urine output etc.

History of past illness :

Not a known case of Diabetes,  hypertension  asthma, tuberculosis, epilepsy, CVA

Surgical history - underwent surgery for renal caliculi 10 years back.

No known allergic history

Personal history :

Diet - mixed

Appetite - decreased

sleep - adequate

Bowel and Bladder movements - regular

Addictions - beedi since 30 years 1 pack per day.

              Alcoholic for 10 years, 90 ml per day.

            

Drug history :

Insignificant

Family history :

No significant family history

General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

at the time of examination

he is examined in a well lit room, with consent taken

he is moderately built and well nourished

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Edema - absent

Vitals : on the day of admission (28/8/2021)

Temperature -102 degrees F

Pulse rate - 96 bpm

Respiratory rate - 20 cpm

Blood pressure - 90/50 mmHg

Day 2 -29/8/2021 :

Temperature-98.6 degree F

Pulse rate - 92 bpm

Respiratory rate - 22 cpm

Blood pressure - 130/80 mm Hg

SpO2- 96%

GRBS - 132 mg/dl (8:00am) ,189 mg/dl (12:00 pm)

 Day 3 -30/8/2021

Temperature - 98 degrees F

Pulse rate - 80 bpm

Blood pressure - 130/70 mmHg

SpO2 -98% on room air (8:00am)

GRBS - 132 mg/dl (8:00am) ,120 mg/dl (8:00 pm)

Day 4 - 31/8/2021 

Temperature - 98 degree F

Pulse rate -80 bpm (8:00am)

Blood pressure -120/70 mmHg

SpO2 - 96% on room air(8:00am) 

GRBS - 132 mg/dl (8:00am) ,138 mg/dl (2:00 pm)

Systemic examination :

CVS : S1 and S2 heart sounds heard

      NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - centrall

                        Vesicular breathsounds heard

Wheeze on inspiration in all the areas.

CNS : intact

ABDOMEN : shape of abdomen -obese

              Soft and non-tender

              No palpable masses

              Bowel sounds heard 

              NO organomegaly

Investigations :

RFT : 28/8/21 (on the day of examination)

Urea - 37 mg/dl

Creatinine -1.3 mg/dl

Sodium - 142 mEq/L

Potassium -3.1 mEq/L

Chloride -104 mEq/L

ABG : 28/8/21 (on the day of examination)

PH - 7.5

PCo2 - 22.6

Po2 - 51

So2 - 85

HCo3 - 15.7

Random blood sugar : 28/8/21 (on the day of examination) - 123 mg/dl

RT-PCR :  28/8/21 ( on the day of admission)

CT chest : 28/8/21 (on the day of admission)

Hemogram:  28/8/21 ( on the day of admission)

Complete urine examination (CUE) :  28/8/21 (on the day of admission)

Blood grouping : 28/8/21 (on the day of admission)

 Ultrasound report : 29/8/21 (on day 2 of admission)

Review Ultrasound On 30/8/21 : diffuse abdominal tenderness.

Colour doppler 2D Echo : 30/8/21 (on day 3 of admission)

ECG:

Fever charting :

Provisional Diagnosis :

 Viral pneumonia ?

Treatment :

28/8/21 : (on the day of admission)

1) Head-end elevated.

2) O2 inhalation to maintain SPo2 > or equal to 94%

3) Inj. Ceftriaxone 1mg Iv/BD

4) Inj. Pantop 40mg Iv/OD

5) Inj. Neomol 100ml Iv/sos ( if the temperature is >      or equal to 101° F)

6)Nebulisation - with Budecort: 6th hourly

                        Duolin: 8th hourly

                        Mucomist: 6th hourly

7)Tab. Paracetamol - 650mg PO/IID

8)Tab. Montex LC - PO/HS

9)BP/PR/RR/Temperature - 4th hourly