A 52yr old male with breathlessness since 3months

 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 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 inputs on the 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.

Chief complaints : 52 yr old male came in with the chief complaint of breathlessness since 3 months


HISTORY OF PRESENTING ILLNESS :

A 52 yr old male, woodcutter by occupation and a resident of suryapet presented to the opd with the chief complaint of breathlessness NYHA class since 3 months, which was more during the nights or evenings than in mornings. 

H/o orthopnea, seasonal variation present. It was not associated with chest pain/PND/Syncope. 

No H/o burning micturition/oliguria/pedal edema//palpitations/abdominal pain/nausea/fever/diarrhoea 

It is sometimes associated with excessive sweating + not associated with chest pain/palpitations/breathlessness 


PAST HISTORY :

Patient developed vitiligo 10yrs ago with areas of hyperpigmentation, hypopigmentation and depigmentation.

A keloid scar on chest post CABG





  On 4 episodes of palpitations and sweating in a period of 3 months he sought for consultation CAD-TVD S/p - CABG 3 Grafts @ 2021 November 

N/K/C/O HTN/DM2/Epilepsy/TB/CVA/Thyroid disorders/Asthma


TREATMENT HSITORY : 

treated for CAD-TVD in 2021 November


PERSONAL HISTORY : married

 Occupation - woodcutter

Appetite - normal 

Non vegetarian 

Chronic Alcoholic used to be regular but stopped the intake 4yrs ago


Family history: insignificant 


PHYSICAL EXAMINATION:


A. GENERAL EXAMINATION : 


Pallor - no

Icterus - no

Cyanosis - no

Clubbing - grade 1 

Lymphadenopathy - no

Odema of feet - present bilaterally grade 2 up to knee, pitting type



















Vitals : 

Pr - 84 bpm

Bp - 130/80 mmhg

RR - 19 cpm

GRBS - 154 mg%


SYSTEMIC EXAMINATION :

CVS : No thrills

          Cardiac sounds - S1 & S2 heard

          Visible raised JVP


RS : Dyspnoea : orthopnea +, NYHA grade 1

        Position of trachea : central

        Breath sounds : vesicular

        Adventitious sounds : b/l rhonchi + in Infrascapular, interscapular and infraaxillary area

  B/L airway entry present



P/A : Soft, non tender abdomen, bowel sounds heard and no organomegaly observed


CNS : No FND

           HMF - intact

           Sensory system - normal

           Motor system - Normal

           No focal neurological deficits



INVESTIGATIONS:





























PROVISIONAL DIAGNOSIS : 

     1. Asthma

     2. CAD-TVD - s/p CABG - TRIPLE GRAFT (2yrs ago)

                         C/o breathlessness of grade 1 NYHA




Treatment : 1. Tab. ECOSPORIN 75mg po H/S

                     2. Tab. MET-XL 12.5 PO/OD (at afternoon)

                     3. Tab. ROSUVASTATIN 20mg po H/S (at night)

                     4. INHALER BECLOMETHASONE 

DIPROPIONATE 200 mg/ sos


 

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