65 years old male with shortness of breath

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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.

Chief Complaints:

Shortness of breath since one day 

Cough since one day 

Difficulty of vision in left eye since 1 year

History Of Presenting Illness:

Patinet was apparently asymptomatic 1days back then he developed shortness of breath which was sudden in onset and gradually progressive and of grade II MMRC and not associated with wheeze, aggravates on exertion,relieved on rest,no orthopnea,No PND

C/O cough which is non productive,no aggravating and relieving factors.

C/O chest pain left side which is non radiating ,diffuse,dull aching type associated with sweating and palpitations 

No c/o chest tightness,fever,hemoptysis

C/o difficulty in vision which is inscidious in onset and gradually progressive.

Past History:

H/o similar complaints 2months back and used local medication 

No h/o inhaler usage 

K/c/o diabetes and hypertension since 8months and on irregular medication

N/k/c/o Tuberculosis,bronchial asthma,epilepsy,CAD.

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions:Tobacco smoking 1 pack beddi/day for 20years , stopped since 10years.

Alcohol occasionally.

Family History:

Not significant 

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Moderately built and nourished.

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

Vitals:

Temperature - 98*F

PR :- 93beats per minute 

BP :- 110/70mm Hg

RR:-18 cycles per minute

SpO2-98%

Systemic examination:

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Auscultation-

S1S2 heard 

No murmurs heard

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

Measurements 

AP diameter-16cms

Transverse -26cms 

Tactile vocal

Fremitus                   Right              Left

Supraclavicular          N                  N

Infraclavicular           N                   N

Mammary                   N                   N

Inframammary          N                   N

Axillary                        N                   N

Infraaxillary               N                    N

Suprascapular           N                    N

Infrascapular            N                     N

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary               NVBS             NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary            NVBS              NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

No focal neurological deficit.

Per Abdomen:

Soft,non tender 

No organomegaly

Investigations:

Liver Finction test:

Total bilirubin-1.08mg/dl

Direct bilirubin-0.32mg/dl

SGOT-11 IU/L

SGPT-14IU/L

Alkaline phosphate-179

Total proteins-6.7g/dl

Hemogram:

Hemoglobin-11.6gm/dl

Total count-7700cells/m3

Platelets:2.2L

Renal function test:

Urea-26mg/dl

Creatinine-1.1mg/dl

Uric acid -2.4mg/dl

Chloride-108

Sodium-135mEq/L

Potassium-4.1

Provisional Diagnosis:

Acute bronchitis

Treatment:

1) NEBULISATION with 

IPRAVENT 6th hourly

BUPECORTI 12th hourly

2) O2 INHALATION with 

NASAL PRONGS SPO >94%.

3) SYP. GRILLINCTUS 15 ml/PO/TID

4) Monitor vitals linform sos.