A 75 YR OLD MALE WITH SOB AND FEVER WITH CHILLS AND RIGOR

A 75 YR OLD MALE WITH SOB AND FEVER WITH CHILLS AND RIGOR

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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.

A. RAJKUMAR 7th Sem Roll 08

A 75 yr old male came with c.c of SOB (grade 3)  since 3 hrs, loose stools 3 episodes, fever 

 with chills and rigors since 6 days. 

H/O PRESENT ILLNESS:  A 75 year male patient mason by occupation was a chronic smoker and alcoholic.

He used to smoke 18 beedis/day for 30 years and 90ml of alcohol per day. He was then diagnosed with TB for

 which he took treatment for 2 years and stopped smoking , drinking regularly.But he then started taking 

occasionally on family gatherings.

Due to repeated episodes of falls he went to govt hospital where the cause was identified to be low BP.

After 5 months he was diagnosed with high BP and started taking medications. 

Patient had pedal edema 1 year back , so he came to KIMS and diagnosed with Renal failure and was

 put on conservative treatment for 4 months followed by medication till now.

Patient had a h/o fall 1 week back and abrasion to head without loss of consciousness.

Patient is having low grade, intermittent fever for 2 days which relieved on medication. He has constipation 

for which dulcoflex was given and then he had loose stools about 3 episodes from 3 hours.

pt is having SOB (grade 3 ) and became irritable.

PAST HISTORY ; 

No similar complaints in the past.

H/O Hypertension and TB

TREATMENT HISTORY: 

Diabetes: No

HTN: Yes

CAD: No

Asthma: No

TB: Yes

Antibiotics: No

Hormones: No

Chemo/Radiation: No

Blood transfusion: No

Surgeries: No

PERSONAL HISTORY:

Married

Appetite is Normal 

Mixed diet 

Bowel and bladder movements are regular

Micturition : Normal

No Known Allergies

Habits : Alcohol occasionally

FAMILY HISTORY:

Diabetes: No

HTN: No

Heart Disease: No

Stroke: No

Cancer: No

TB: No

Asthma: No

Any other hereditary diseases: No

Psychiatrist: No

Sibling History: No

Any other: No

PHYSICAL EXAMINATION:

GENERAL EXAMINIATION

Height 

Weight

BMI

Body surface area

Pallor: present 

Icterus: absent

Lymphadenopathy: absent

Clubbing of fingers: absent

Edema: absent

Malnutrition: No

Dehydration : No

VITALS

Temperature: 98.4 F

Pulse rate: 92/min

Respiration rate 22/min

BP: 150/70 mmhg

SPO2 at room air 90%

GRBS: 120 mg%

SYSTEMIC EXAMINATION

CARDIO VASCULAR SYSTEM

Thrills: No

Cardiac Sounds: S1,S2 heard

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea: No

Wheeze: Yes

Position of Trachea: Central

Breath Sounds: Vesicular

Adventitious Sounds:  Rhonchi

ABDOMEN:

Shape of Abdomen:  Scaphoid

Tenderness: No

Palpable mass: No

Hernial Orifices: Normal

Free Fluid: No

Bruits: No

Liver: Not palpable

Spleen: Not palpable

Bowel sounds: No

Genitals: Normal

Speculum Examination : Normal

PV Examination : Normal

P/R examination: Normal

CNS:.

Level of Consiousness: Consciousness/Alert

Speech: Normal

Signs of Meningeal irritation: No neck stiffness and Kerning's sign.

Cranial Nerves: Normal

Sensory System: Normal

Motor System: Normal

Glasgow Scale: 1

INVESTIGATIONS: 

Hemogram

RBS

Serum Creatinine

Serum electrolytes

LFT

ABG

ECG