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A 75 YEAR OLD MALE WITH CHEST PAIN AND DIARRHEA

 A 75 YEAR OLD MALE WITH CHEST PAIN AND DIARRHEA 


This is an online e log book to discuss our patients' deidentified health data shared after taking his/ her/ guardians consent. Here we discuss our individual patients' problems through a series of  inputs from an available global online community of experts with an aim to solve those patients' clinical problems with the collective current best evidence based inputs. This e- log also reflects a patient centered learning portfolio.  

 

NAME : G PRAVALLIKA

ROLL NO: 41

5TH SEMESTER 

 

A 75 years old man presented with generalised weakness since 1/07/22 and loose motions since 29/06/22.

 

HISTORY OF PRESENT ILLNESS :

 

The patient was apparently asymptomatic 6 years back and got diagnosed with pulmonary TB and took treatment for 2-3 years and got cured. Then patient started smoking again and started developing wheeze. About 2-3 months ago, his wheeze got aggravated and consulted pulmonologist and used medication. After consuming some eggs with curry on tuesday, on wednesday(29/06) he developed 3-4 episodes/day for 2 days which were watery and non blood, non mucus and small quantity. Then he was fine till 1/07 after which he developed generalised weakness and had more eisodes of diarrhea and presented to the hospital on 2/07/22

 

HISTORY OF PAST ILLNESS:

NO H/O  Diabetes, hypertension, tuberculosis, asthma, epilepsy, thyroid, CAD, CVD.

Patient was diagnosed with Pulmonary Tuberculosis 5-6 years ago for which he took treatment and got cured.



 

PERSONAL HISTORY :

 

Mixed diet- until 5-6 months beck after which only vegetarian food is being consumed

Married

Reduced appetite

Adequate sleep

Regular bladder and bowels movements

Addictions- smoking until few years ago now stopped

Occupation: Farmer until 5 years ago now stopped


Patient wakes up at 5 am , does his morning routine such as using the washroom and consumes some tea. After which he rests and eats rice at around 9 am. He consumes little amount of lunch at 2 pm. He actively socialises with friends and family after which he eats dinner at 9 pm and sleeps.

 

FAMILY HISTORY :

 

No history of diabetes, hypertension, asthma, TB, CAD, CVD, polio.

 

GENERAL EXAMINATION : 

 

Patient was conscious, coherent, co - operative. 

Well oriented to time, place, and person. 

Moderately built and moderately  nourished. 

pallor- no

clubbing- no

Icterus- yes

cyanosis- no

lymphadenopathy- no

edema- no

Malnutrition- no 

Dehydration- no

 

 

VITALS :

PR : 82 bpm, regular

Bp :  mm of Hg

Respiratory rate: 26/ min

GRBS :  mg /dl

Temperature: 99 degrees F

SpO2: 92 %


 

SYSTEMIC EXAMINATION:

 

PER ABDOMINAL EXAMINATION :

 

INSPECTION -

 

Shape - obese

Umbilicus - inward

Movements with respiration - normal 

visible pulsations- no 

visible scars or sinuses - no

engorged veins- no

 

PALPATION :


tenderness in any quadrants of abdomen, liver and spleen -  no 


PERCUSSION :

dullness of abdomen- no


AUSCULTATION :

 

 Bowel sounds - no

 

 

CVS EXAMINATION :

 

S1, S2 - heard 

murmurs-no 

Thrills- no

 

RESPIRATORY SYSTEM EXAMINATION :

 

Trachea - central 

Bilateral air entry-

Normal Vesicular breath sounds 

Additional sounds- Rhonchi present 

Wheeze - yes 

Dyspnea - yes

 

CNS EXAMINATION :

 

Level of consciousness- conscious / alert

Speech - normal 

Gait - normal

Sensations - intact 

Cranial nerves - intact

Reflexes - biceps, triceps, supinator, knee, ankle- +4

Neck stiffness: no

Kernig's sign: no

Finger nose coordination: no

Kneel Heel coordination: yes

  

 

INVESTIGATIONS ORDERED : chest x ray, 2D echo, USG chest , USG abdomen , ECG, random bloog sugar, , ABG, CUE, haemogram, electrolytes, LFT


CHEST X RAY



2D ECHO

ECG





USG Abdomen


Haemogram, LFT, Electrolytes, CBC , Urea , creatinine

USG chest 



 


PROVISIONAL DIAGNOSIS: Acute gastroenteritis with old pulmonary koch’s


TREATMENT:

  1. Neb. BUDECORT+ DVOLIN- 8th hourly 

  2. Inj. PAN 40 mg IV/OD

  3. Iv. NS- 0.9% at 100 ml/hr

  4. Inj. OPTINEURON 1 amp with 100 ml NS IV/OD

  5. Tab. ULTRACET ½ tab PO/QID

  6. Tab. NICARDIA 10 mg if BP>140 mmHg systolic

  7. Inj. AUGUMENTIN 1.2g IV/BD

  8. Monitor BP hourly

  9. Tab. ECOSPRIN 75/10 mg OD

  10. Tab. CLEXANE 40 mg SC BD

  11. Syp. CREMAFFIN PLUS 15 ml OD 

  12. Tab. MEF-XC 12.5 mg OD

  13. Tab. LASIX 20 mg BD

The patient is complaining of nausea and severe headache today (8/07)

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