82 year old with cough and cold

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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.

Maheshwari Jagathkari

Intern(2k18)

Case report

A 82 year old resident of Nalgonda came with chief complaints of

Productive cough since 1 month

Abdominal bloating since 6-7 months

History of presenting illness-

Patient was apparently alright 10 years back then H/O ?Malaria, ?Chikungunya 10 years ago, upon further investigations RFTs was deranged for which 1 session of hemodialysis.

H/O ? viral fever 4-5 years ago and deranged which improved as fever subsided.

Now patient presented to casualty with c/o cough that is productive since 1 month, intermittent type with white in colour, mucoid sputum, non blood tinged and non foul smelling without and aggaravating or relieving factors which is resolving since 10 days for which patient visited a local RMP and was advised to get routine health checkup for low blood pressure and pulse rate.

No H/O chest pain, SOB, orthopnea, palpitations, PND.

No H/O fever, nausea, vomiting.

H/O abdominal bloating since 6-8 months, which aggravates on taking spicy and tangy food occasionally.

Patient used Tab.Pan 40 mg PO/OD at 7 am for about 10 days.

Past history

 

No H/O similar complaints in the past.

Not a k/c/o DM2, HTN, Asthma, Epilepsy, CAD, CVA, Thyroid disorders, Tuberculosis.

Personal history

Patient takes a mixed diet with normal appetite, regular bowel and bladder movements.

Addictions- Takes alcohol occasionally

Tambaku and cigarette since he was at the age of 12 years, smokes almost 10 per day.

Daily routine

Patient wakes up at 7 am, gets freshened up and then takes tea at 8 am and eats breakfast at around 10 am, goes to spend time in the village with Neighbours, comes back after an hour or two, has lunner at 1 pm and then takes a nap for an hour or so,wakes up then watches television for sometime, takes tea at around 5:30 pm, takes a stroll again in the neighborhood and has dinner at around 9 pm and goes to bed by 10 pm.

Vitals-

BP-100/60MMHG

PR-57BPM

RR-20CPM

TEMP-AFEBRILE

SPO2-97% AT RA

GRBS-99MG/DL

GENERAL EXAMINATION

Pallor is absent.

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

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, no murmurs

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

CNS EXAMINATION

Right Handed person, uneducated 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE 26/30

speech : muffled, unclear

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

Intact

MOTOR EXAMINATION:        

               Right Left

   

BULK UL Normal Normal

            LL Normal Normal

TONE UL Normal Normal

             LL Normal Normal

POWER UL 5/5 5/5 LL 5/5 5/5

REFLEXES

                           Right Left

BICEPS ++ ++

TRICEPS ++ ++

SUPINATOR ++ ++

KNEE ++ ++

ANKLE ++ ++

PLANTAR flexor flexor

SENSORY EXAMINATION: intact

PROVISIONAL DIAGNOSIS

?UPPER RESPIRATORY TRACT INFECTION

? TUBERCULOSIS

? GASTRITIS

INVESTIGATIONS

COMPLETE BLOOD PICTURE

HB- 13.2gm/dl

Total count-7,600 cells/cumm

Platelets-2.32lakhs/cumm

Smear-Normocytic normochromic

Serum creatinine-2.1mg/dl

Blood urea- 55mg/dl

RBS-99mg/dl

Serology is non reactive for Hbsag,HBV and HIV

Chest x ray

USG ABDOMEN

Complete urine examination

Liver function test

Serum electrolytes

ABG

Upon investigations patient was found to have CHRONIC KIDNEY DISEASE which may have been after the attack of ? malaria? Chikungunya 10 years back.

TREATMENT

TAB.AZITHROMYCIN PO/OD

TAB.PANTOP 40MG PO/OD/BBF

TAB.DOLO 650 MG SOS