CASE DISCUSSION- 80 year old Male with Lower back pain, cough and shortness of breath


RACHANA GANGULA 

ROLL NO 110

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"


80 YEAR OLD MALE PATIENT WITH LOWER BACK PAIN, COUGH AND SHORTNESS OF BREATH 



 A 80 year old male patient resident of Bhongir, who was an agricultural worker until 4 years ago and is now unemployed, presented to the OPD on 16/11/21 with chief complaints of 

  1. shortness of breath since 20 days
  2. cough since 20 days and
  3.  lower back pain since 10 days. 
Patient was apparently asymptomatic 20 days back, then he developed productive cough.
Sputum was white in color, non blood stained, non-foul smelling. No diurnal variation in sputum production was noticed. 
Cough was sudden in onset. No progression. Aggrevated on lying down and walking. Relieved on using medication given by local RMP. 

Fever with chills and rigor for 3 days before admission
Loose stools on Day 2 of admission, 3 episodes in a period of 6hours- watery in consistency 
Nausea present, since past 10 days.

This was associated with shortness of breath which was initially Grade IV but it subsided on treatment with medication from another hospital.
Patient started the treatment around 10 days ago. 

Patient complains of bilateral lower Back pain since the past 10 days. 
Type of pain- squeezing pain
No aggrevating or relieving factors 
Not progressive
Not Radiating 
Patient is unable to walk without support because of the lower back pain. 


PAST HISTORY


Patient has joint pains in both knee joints and wrist joints since the past 10 years and has been using analgesic medication given by local RMP- 1 tablet every two days since the past 10 years.

Patient has itching throughout the body since the past 1 year and has been using a lotion to control the itching, prescribed by local RMP everyday before taking a bath since the past 1 year.
 
Patient lost sight in the right eye around 50 years ago from a household accident. He was gathering and beating firewood to kindle a fire in his household and during that process. It was associated with bleeding from the eye and subsequent loss of vision in the entire right eye. 

Not a known case of Diabetes Mellitus, Hypertension, epilepsy, tuberculosis. 

PERSONAL HISTORY

Patient consumes a mixed diet. 
Sleep is adequate, until 20 days ago when he was not able to sleep well because of the SOB. He is able to sleep well after starting medication 10 days ago. 
Bowel and bladder movements are regular until day 2 of admission.

Addictions- 
Smoked bidi (5 per day) for 15 years. Stopped 20 years ago 
Drinks Toddy everyday since past 50 years. (500ml/day) 
No Allergies


GENERAL EXAMINATION


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

Pallor - absent
Icterus - absent 
Cyanosis - absent 
Clubbing - absent 
Lymphadenopathy- absent
Edema- absent 

Vitals- 

BP- 110/70 mmHg
Pulse- 65bpm
Respiratory Rate- 14 cpm
Temperature- afebrile 

RESPIRATORY EXAMINATION

INSPECTION-
Shape of chest- elliptical in shape 
Symmetry- symmterical on both sides, no unilateral bulge 
Subcostal angle- 90°
No retractions, scars or sinuses
Trachea- midline 
Prominent LEFT STERNOCLEIDOMASTOID
No visible apical impulse 
Trail sign -ve
Respiratory movements- symmterical movements of chest on inspiration and expiration are seen.

( Prominent carotid pulsation in Carotid Triangle) 
PALPATION-
Normal tracheal length 
No tracheal shift 
Apical Impulse- 5th ICS on midclavicular line 

PERCUSSION

AUSCULATION



INVESTIGATIONS 



5 days before admission -HOSP 1
HRCT THORAX
5 days before admission- HOSP 1
CRP- ELEVATED- 182 mg/dL




day of admission- HOSP2
BIOCHEMICAL INVESTIGATIONS
day of admission- HOSP2
RADIOLOGICAL INVESTIGATIONS



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