A 70 Year Old Male With Breathlessness and Decreased Appetite

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I have 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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

Ankur Kumar 

CASE REPORT : 

A 70 Year Old Male Patient, Agricultural Labourer by occupation, Presented with Chief Complaints of Breathlessness and Decreased Appetite Since 4 Days.

Patient came to the hospital 6 months ago with chief complaints of high grade fever insidious in onset that is associated with chills and rigors, intermittent type relived with medication. Later he developed Generalized weakness insidious in onset which led to his inability to perform his daily activities and was brought to hospital.

There was H/O Giddiness, H/O Fall (Twice), H/O Loss of Consciousness for 5 min.

Reference : https://maheshwarijagathkari57.blogspot.com/2023/06/66-year-old-with-high-grade-fever-and.html

Patient came to the hospital again as 4 Days ago then he developed Breathlessness insidious in onset Gradually Progressive, exaggerated after food intake and relieved with rest.

Patient has a History of fall in the Bathroom one week ago.

Decreased Appetite Since 4 Days.

No H/O Cough, Cold, Fever

No H/O Abdominal Pain / Burning Micturition

No H/O Chest Pain, Palpitations, Loose motions, Profuse Swellings.

PAST HISTORY : 

K/C/O  HbsAg Positive On Treatment 

K/C/O DM Since 20 Years on Treatment ( Inj. HAI)

K/C/O Hypertension on Treatment

K/C/O CVA (Acute Infarct in Right Frontal Lobe) on Treatment (Antiplatelets)

K/C/O CKD ( Stage - III )

Left Lower Limb and Scrotum Filariasis  on Treatment

Personal History : 

 Diet - Mixed

Appetite - Decreased

Bowel and Bladder - Normal

Addictions - Consumed Alcohol Everyday ,

                      1-2 pegs daily for past 4 years.

                     Smoked a pack of beedis a day, Quit 7                       years ago.        

Family History: 

No Significant Family History

General Examination: 

Pallor is Present

Pedal Edema is Present

No features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy.

Pedal Edema in Right Lower Limb

Left Lower Limb with Filariasis

Pics

6Months (June) ago Vs Today( November)

Patient has lost significant Muscle mass in the past 6 months.

 

Vitals : 

Temperature - 98.4 F

PR - 86/min

RR - 17 CPM

BP - 140/80 mmHg

SpO2 - 77% at RA.  

             98% with 10 lit. of O2

SYSTEMIC EXAMINATION :

ABDOMINAL EXAMINATION : 

INSPECTION :

No distention, No scars

Umbilicus - Inverted

Equal symmetrical movements in all the quadrants with respiration.

No visible pulsation, peristalsis, dilated veins and localized swellings.

PALPATION :

No local rise of temperature, Abdomen is soft with no tenderness.

No spleenomegaly, hepatomegaly

PERCUSSION

Liver span is 12cm, No hepatomegaly

Fluid thrill and shifting dullness absent.

No puddle sign.

AUSCULTATION

Bowel sounds present.

CVS- S1 and S2 heart sounds heard. 

RS- Bilateral air entry is present, normal vesicular breath sounds heard.

RS :  BAE + 

Crepts present in the

 Right -  MA, IAA, ISA

  Left -    MA, ISA

     

CNS EXAMINATION

Right Handed person, uneducated 

HIGHER MENTAL FUNCTIONS:

Patient is Conscious,  Coherent, Cooperative

Speech : Muffled, Not Clear

Behaviour : Normal 

Memory : Intact.

Intelligence : Normal

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION: Intact

MOTOR EXAMINATION:        

                   Right.      Left

  

POWER 

           UL  4/5           O/5 

           LL  4/5.           3/5

REFLEXES

                           Right      Left

BICEPS                +++      ++

TRICEPS               ++       +

SUPINATOR         +++     ++

KNEE                    +++    +++

ANKLE                   ++      ++

PLANTAR.     Flexor       flexor

SENSORY EXAMINATION: Intact

PROVISIONAL DIAGNOSIS: 

Hypertension

Diabetes Mellitus

Chronic Kidney Disease Stage III

CVA ( SubAcute Infarct in Right Frontal Lobe)

HbsAg Positive

Left Lower Limb Elephantiasis

 INVESTIGATIONS :

ECG : 

X Ray Chest

X- Ray C - Spine 

X-Ray 

Serology: 

HbsAg - Positive

HIV. - Negative

HCV - Negative 

USG : 

23/11/23

Hemogram : 

LIPID PROFILE : 

Fasting Blood Sugar - 216mg/dl

RFT : 

24/11/23

CT BRAIN 

Hemogram

RFT

Serum electrolytes : 

Serum Magnesium - 2.1 mg/dl

Urinary Electrolytes : 

Urinary Chloride - 189 mmol/L

Urinary Sodium - 148 mmol/L

Urinary Potassium - 23.02

25/11/23

RFT

Hemogram

Complete Urine examination

ESR 

26/11/23

Hemogram

RFT

CUE

APTT

PT

27/11/23

CT ABDOMEN

CBP

COMPLETE URINE EXAMINATION

LFT

RFT

Treatment

1) RT feeds water - 100 ml - 2nd hourly, milk - 50ml + Protein powder 3rd hourly.

2) Inj. HAI SC TID (8U-8U-8U)

3) TAB. Lasix 20mg RT/OD 

4) Tab. Amiodipine 5 mg RT/OD 

5) TAB. Ecospirin 75mg RT/OD

6) Tab. Clopidogrel 75mg RT/OD

7) Tab. Atorvastatin 20mg RT/OD

8) Tab. Orofer xt RT/OD

9) Tab Nodosis 500 mg RT/BD

10) Tab. Shelcal ct RT/OD

11) Cap. Bio- D3 RT/OD

12) Inj. PCM 1gm IV /SOS

13) Syp. Cremaffin 15ml RT/TID