A 50 year old male patient with facial puffiness and sob

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."


I’ve 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:

* fever and sob since 1 day 
* facial puffiness since yesterday morning

HOPI:

Patient was apparently asymptomatic 1 day back then he developed fever which is of low grade , intermittent relieved with medication ,associated with chills and rigor Associated with generalised body pains .
 
 SOB since 5 hours which is sudden onset grade 3 not associated with chest pain, palpitations , pedal odema, decreased urine output

No c/o cough ,cold ,burning mitcturation, vomitings ,loose stools ,pain abdomen . 

PAST HISTORY:

K/c/o htn since 1 yr on tab amlodipine 5 mg plus atenolol 50 mg po od . 

Not k/c/o DM, asthma , TB, epilepsy, CVD

PERSONAL HISTORY:

He is married. 

 Mixed diet. 

Appetite :Normal

Micturtion: normal

Bowel and bladder habits : normal
 
Sleep :Normal 

Alcohol and smoking history: Drinks occasionally . 
Smokes daily 10 beedis/ day stopped 15 days 

FAMILY HISTORY:

No family h/o  HTN, TB, heart disease,cancers, epilepsy. 


GENERAL EXAMINATION : 

Pt is conscious coherent cooperative well oriented with time place and person . 

PALLOR : absent

ICTERUS : absent

CYANOSIS :Absent

CLUBBING :Absent
 
GENERALIZED LYMPADENOPATHY :Absent

ODEMA: Absent


Vitals:

Bp:150/80 mm of Hg

PR : 60 bpm

RR  :22 cpm

Temp :97.3 

SPo2 : At room air 74 % and 99 % at 6 litres of O2

Grbs: 116


  
SYSTEMIC EXAMINATION :


CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• Dysponea present

* No wheezing

• Postion of trachea - central

• Breath sounds - Vesicular
 
* Adventitious sounds : Diffuse bilateral crepts present

ABDOMEN:

• Shape  : scaphoid

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

CNS:

• Conscious and coherent

• Speech - normal 

No signs of meningeal irritation

• Glass gow coma scale - 15/15

CLINICAL IMAGES :



Investigations :


PROVISIONAL DIAGNOSIS: Pyrexia evaluation ( LRTI? COPD?)

TREATMENT: on 26/10/2023

Iv fluilds 
INJ augmentin  m 1.2 gm iv tid 
INJpan  40 mg iv od bbf 
INJ neomol 1gm iv/sos 
Tab atorvastatin 20 mg po/hS 
Tab ecosporin 75 mg po HS 
TAB AZITHROMYCIN 500 mg po od 
Tab oseltamavir 75 mg po bd 
Nebulisation with duolin and bedecort 

O2 supplementation






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