67 year old male presented with SOB qnd back pain

This is an 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 patient's 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 the comment box"

   
A 67 YEAR OLD MALE WHO IS A FARMER BY OCCUPATION CAME WITH C/O PEDAL EDEMA SINCE 6 MONTHS,

SOB GRADE-2 SINCE 2 MONTHS,

 AND COMPLAINTS OF LOW BACK ACHE SINCE 2 MONTHS.

  Timeline of events


NOT A K/C/O DM,HTN,BA,TB

TREATMENT H/O-NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS

PERSONAL H/O-

MARITAL STATUS-MARRIED

OCCUPATION-FARMER

APETITE -NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)

FAMILY H/O-NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION-
PT C/C/C
PEDAL EDEMA PRESENT,NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY

NOT A K/C/O DM,HTN,BA,TB

TREATMENT H/O-NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS

PERSONAL H/O-

MARITAL STATUS-MARRIED

OCCUPATION-FARMER

APETITE -NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)

FAMILY H/O-NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION-
PT C/C/C
PEDAL EDEMA PRESENT,NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY


NOT A K/C/O DM,HTN,BA,TB

TREATMENT H/O-NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS

PERSONAL H/O-

MARITAL STATUS-MARRIED

OCCUPATION-FARMER

APETITE -NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)

FAMILY H/O-NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION-
PT C/C/C
PEDAL EDEMA PRESENT,NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY


NOT A K/C/O DM,HTN,BA,TB

TREATMENT H/O-NO KNOWN DRUG ALLERGIES ,ON INHALERS I/V/O COPD SINCE 2 YEARS

PERSONAL H/O-

MARITAL STATUS-MARRIED

OCCUPATION-FARMER

APETITE -NORMAL

BOWEL AND BLADDER MOVEMENTS REGULAR

ADDICTIONS-NON SMOKER
ALCOHOL-OCCASIONAL INTAKE (LAST BINGE -6 MONTHS BACK)

FAMILY H/O-NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION-
PT C/C/C
PEDAL EDEMA PRESENT,NO PALLOR ,NO ICTREUS,NO CYANOSIS,NO LYMPHADENOPATHY







VITALS-
TEMP-101 F
BP-120/80 MM HG
PR-110 BPM
RR-28/min
SpO2-88% @ RA, 99,%@ 5 L OF O2
GRBS-133 MG/DL

SYSTEMIC EXAMINATION-

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- present.

Vocal fremitus- normal on both sides

Measurements:

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapula

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

 Vesicular breath sounds

Rhonchi heard.

Decreased breath sounds.


Cardiovascular system:

JVP- raised.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.


Abdominal examination:

Abdomen distended, umbilicus- inverted

Soft, tenderness present

No organomegaly.





CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.                   LFT
BICEPS-.        1+.                      1+
TRICEPS-.      1+.                      1+
SUPINATOR- 1+.                       1+
ANKLE.        -. 1+.                       1+
KNEE-.            1+                         1+

INVESTIGATIONS-


SEROLOGY-
NEGATIVE

TROPONIN-I - NEGATIVE

ECG-



X-RAYS 










FEVER CHART



CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.                   LFT
BICEPS-.        1+.                      1+
TRICEPS-.      1+.                      1+
SUPINATOR- 1+.                       1+
ANKLE.        -. 1+.                       1+
KNEE-.            1+                         1+

INVESTIGATIONS-


SEROLOGY-
NEGATIVE

TROPONIN-I - NEGATIVE

ECG-



X-RAYS 










FEVER CHART


2D echo








USG 




DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



TREATMENT-

1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD


SOAP UPDATES
27/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.                   LFT
BICEPS-.        1+.                      1+
TRICEPS-.      1+.                      1+
SUPINATOR- 1+.                       1+
ANKLE.        -. 1+.                       1+
KNEE-.            1+                         1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG  IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG  PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG)  x PO/OD

9.INTEEMITTENT CPAP 4TH HOURLY




SOAP UPDATES
28/3/22

67YEAR/male

S-C/o SOB
PEDAL EDEMA DECREASED
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT. LFT
BICEPS-. 1+. 1+
TRICEPS-. 1+. 1+
SUPINATOR- 1+. 1+
ANKLE. -. 1+. 1+
KNEE-. 1+ 1+


A-DIAGNOSIS-COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION



P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY

2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX

3.STRICT I/O CHARTING

4.VITALS MONITORING EVERY 4TH HOURLY

5.TAB DOLO -650 MG /PO/SOS

6.TAB HYDRALAZINE 12.5 MG PO/BD

7.TAB CARVEDILOL 3.125 MG PO

8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD

9.INTEEMITTENT CPAP 4TH HOURLY






















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