40yr male

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.came to the hospital with

CHEIF COMPLAINTS: of  breathlessness since 20 days 

Cough since 20 days  .

HOPI: patient was apparently asymptomatic 20 days back later he developed breathlessness MMRC grade 3 not associated with wheeze  , no orthopnea, PND aggravated  more on  sleeping on left side, relived wen Lying down  on right side  

Cough non productive ,  associated with chest  tightness , loss of weight, loss appetite since 20 days

 Low grade fever with evening rise of temperature, associated with chills and rigors, relieved on medication

No complaints of chest pain , palpitations ,decreased urine out put , was admitted in  pulmonology department  on 2/11/22 and being followed up by general medicine department in view of elevated trop I 310, ecg changes  showing deep T inversions in V1- V6 leads, P- pulmonale QT- 0.4 secs.l

On 4/11/22 

7:20 pm the case was transferred to general medicine in view of 2Decho changes RWMA+,LAD akinetic LCX&RCA hypokinetic,  EF - 40 , for further evaluation and management 

Past history: 

History of similar complaints 20 days back  , treated locally

K/c/o Pulmonary TB.( Sputum positive in 2020 )used,  ATT for 2 months later stopped 

 And started again since 20 days

K/c/o RVD positive detected 2020 , used for 2 monthsTlD+ Doltogravir and stopped later, and started 20 days back.

Not a known case of DM,/HTN/CAD/epilepsy

Personal history:

Pt is lorry driver by occupation

 Diet: mixed

Appetite: decreased since 20 days

Bowel and bladder movements: regular

 Sleep : adequate

Addictions: consumes regular alcohol 180ml  per day since 20 yrs

 Chews guttkha 1 packet per day  since 20 yrs

 General examination: 


Patient conscious, coherent, cooperative

Well oriented to time place and person

No pallor.Noicterus,cynosis, clubbing,lymphadenopathy ,odema 

Vitals:

Temp : 99.7f

Bp:80/60mmhg

Pr:104bpm

Rr:40 cpm

Spo2 - 74 @ ra 

96with 4 liters of o2

Grbs:166

SYSTEMIC examination:

 CVS: S1,S2 +

Respiratory system:  

UPPER RESPIRATORY  TRACT:

NOSE: no dns; polyps

Oral cavity:  poor oral hygiene

Posterior pharyengeal wall:normal

Lower respiratory tract:

Shape of chest -bilateral asymetrical,

 Right side chest muscle mass- loss of suppraclavicular and infraclavicular hallowness

Left side chest movements decreased

 No crowding of ribs, 

Wasting of muscles-ve Usage of accessory muscles+

Spinoscapular distance equal on both sides.

palpation: all inspectory findings confirmed, 

No local rise of temperature

Apex beat felt at inch medial to MCL

Tactile vocal fremitus equal on bs

Percussion: 

 Direct percussion: resonant on clavicle and manubrium

   Indirect percussion:resonant in all areas  and dull on left lower lobe

Auscultation:Auscultation 

BAE+(decreased breath sounds on left lower lobe)

B/l Crepts present on supraclavicular infraclavicular,midaxillary,infra axillary,supra scapular,infra scapular

PROVIOSIONAL DIAGNOSIS:

RIGHT UPPER LOBE, LEFT UPPER LOBE LOWER LOBE  CONSOLIDATION LEFT UPPER LOBE CAVITY 2° to  TB? PCP WITH RVD+ 

investigations :2/11/22

Ecg
4/11/22
5/11/22; 8:00am

 

5/11/22
9:30 am

TREATMENT 

INJ THAMINE 1 AMP IN 100 ML NS/IV/BDA

ATT 3 DRUGS PER DAY UNDER NTEA

ART TLD+ DOLTOGRAVIR

INJ PIPTAZ 4.5 GM IV/TID

INJ HYDROCORTISONE 100 MG IV

INJ NORAD @ 8ML PER HR

INJ CLEXANE 40 MG SC BD

INJ LASIX 40 MG IV/BDIF SBP >= 110MMHG

TAB ECOSPIRIN 75MG PO/OD

TAB BACTRUM DS  OD/PO

TAB PCM 650 MG PO BD

SYRUP GRILLINCTUS OX 2TSP PO TID


Diagnosis: 

CAD (triple vessel disease) HFrEF with (EF EF-48%) WITH LEFT SUPERIOR PULMONARY VEIN THROMBUS WITH TYPE 2 RESPIRATORY FAILURE SECONDARY TO B/L PULMONARY .T.B. ON ATT WITH ?SUPER INFECTION WITH ? PCP WITH ? CAP VTH RVD +VE ON ART

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