61 years old with SOB

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I have been assigned this case to develop my competency in reading and comprehending clinical data, including the patient's history, clinical findings, and investigations, in order to come up with a diagnosis and treatment plan.

Case taken by Sangha Mithra

Case Summary:

Cheif complaints: Patient came to the casualty with the complaints of breathlessness since since 1 year and abdominal distension from 2 months.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year  back then he had flank pain for which he was hospitalised and got diagnosed with renal stones and got treated 2 months ago by lithotripsy SOB (grade-II) since 1 year which is gradually progressive and Progressed to grade-IV in the span of 1 year .

No H/o Burning micturition 

No H/o decreased urine output. 

No H/o cough, cold

No H/o chest pain, palpitations

No H/o abdominal pain, nausea, Vomiting, loose stools

 

Family History:

- Not significant.

Personal History:

- Mixed diet, normal appetite, No addictions.

GENERAL EXAMINATION

PATIENT IS CONSIOUS, COHERENT AND COOPERATIVE NO PALLOR, ICTERUS.CLUBBING, CYNOSIS, LYMPADENOPATH

VITALS

BP: 130/80 MMHG

PR.86 BPM

RR: 18 CPM

SPO2:98%*

SYSTEMIC EXAMINATION;

Respiratory system:

 Inspection: chest shape : bilaterally symmetrical elliptical 

Movement : bilaterally symmetrical

No scars , sinuses , engorged veins 

Trachea appears to be central

Palpation: No rise in temperature and no tenderness , Apex beat felt at 5 intercostal spaces.

Expansion of chest is bilateral symmetrical in anterior, apical and posterior areas.

Trachea location central .

Tactile vocal fremetus : resonant in all areas 

Percussion: All areas appears are resonant.

Auscultation:BAE present, No added sounds

Per abdomen:

Inspection:

 Shape of abdomen: flat

Umbilicus: Inverted and central

No visible pulsation, scars, swelling, sinuses, dilated veins .

Palpation: 

No local rise of temparature and tenderness 

Percussion: 

No fluid thrill, shifting dullness absent

Auscultation: 

Bowel sound heard 

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:No local rise of temparature and no tendersness

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs.

CNS :

Mental state examination:

Appearance : hygiene maintained groomed 

Mood : fine ( she wants to go home or she wants her phone back )

Thought process : normal 

Perception : auditory and visual Hallucinations ( seeing snakes and someone calling her)

Orientated and conscious 

Memory: long term :good 

Short term : on 22nd June after 12am she wished her sister and slept after that She doesn’t remember anything till today morning she just remembered one or two events from yesterday 

Immediate: good

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : Visual acuity is normal

3rd,4th,6th : Pupillary reflexes present

 EOM full range of motion present        

 5th : Sensory intact

          Motor intact

 7th : normal.

8th : No abnormality noted.

9th,10th,11th,12th : normal.

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch Present 

Pain Present 

Temperature Present 

DORSAL COLUMN SENSATION:

Fine touch Present 

Vibration Present 

Proprioception Present 

CORTICAL SENSATION:

Two point discrimination Present 

Tactile localisation Present 

CEREBELLAR EXAMINATION:

 Finger nose test able to perform 

  Heel knee test able to perform

  Dysdiadochokinesia able to perform

Speech Normal 

Rhombergs test Absent

SIGNS OF MENINGEAL IRRITATION: 

Kernig's sign, brudzinski sign, neck rigidity absent

 

MOTOR EXAMINATION:

                                        Right Left

                                         UL LL UL LL

                       BULK: Normal Normal Normal Normal

                       TONE : Normal Normal Normal Normal

                    POWER : 5/5. 5/5. 5/5. 5/5

SUPERFICIAL REFLEXES:

CORNEAL present       

CONJUNCTIVAL present

DEEP TENDON REFLEXES normal 

REFLEXES: BICEPS TRICEPS SUPINATOR KNEE ANKLE

RIGHT +2 +2 +1 +2 +2

LEFT +2 +2 + 1 + 2 +2

Provisional diagnosis : Shortness of breath under evaluation