A 75 yr old patient

This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findingsfindings investigations and come with a diagnosis and treatment plan. 

A 75 yr old Male patient presented to casualty with chief complaints of 
                    - Generalized weakness since 1 day
                    - loose stools and dehydration since 5 days
                    -SOB and chest pain since 1 day 
    
HOPI
  
Patient was apparently asymptomatic 6yrs back and was diagnosed with pulmonary  TB and took treatment for 1 yr and cured .Then patient started smoking again and th n 3yrs back he developed wheeze and then he used medication but continued to smoke.He was fine 3months  and his wheeze got aggregated and was  consulted a pulmonologist and was using medication .Then 5 days back he developed loose motions 3-4 episodes for day  for 2 days  which were non blood non mucus ,watery and small quantity  then he was fine till yesterday and then had 2 episodes  and also developed generalized weakness for which he went to hospital  and took treatment . 
 
PAST HISTORY
5 yrs ago he was diagnosed with TB for which he took treatment for 1yr and got cured.
N/K/C/O HTN,DM,ASTHMA, EPILEPSY 

PERSONAL HISTORY
Married
Appetite is lost
Non vegetarian
Irregular bowels
Abnormal micturition
He is alcoholic and smoker

FAMILY HISTORY
Not significant

GENERAL EXAMINATION
Pt is c/c/c 
No pallor,cyanosis, lymphadenopathy,clubbing,edema of feet
Icterus present
VITALS
Temperature:99 F
 Pulse rate:82/min
 BP: 90/60
SpO2: 92%
SYSTEMIC EXAMINATION
CVS: S1+,S2+
RESPIRATORY SYSTEM: Presence of Dyspnoea,wheeze with vesicular breath sounds

PROVISIONAL DIAGNOSIS: OLD PULMONARY KOCHS. 

FEVER CHART
.      COLOUR DOPPLER 2D ECHO


ULTRASOUND REPORT
ECG
4/7/22

5/7/22
     7/7/22        
CHEST X- RAY REPORT.    5-7-22

TREATMENT HISTORY

1. Nen. Budecort /Duoline 8th hrly
2. Inf.NS /RL 0.9% 100 ml/he
3.Inj.40 mg i.v OD 
4.Inj.Optinuron 1 amp 3N 100 ml NS,I V OD
5.T.Ultracet 112  QID
6.T.Nicardia 10 mg 
7. Inj.Augumentin 1.2 mg i.v BID
8.Moniter BP 4th hrly






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