65 yr old male with sob , fever since 1 month

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

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CHIEF COMPLAINTS 

A 65 yr old male construction worker by occupation came with complaints of

      •yellowish discoloration of eyes since 1 month

     • Cough & SOB since 1 month

      • Burning micturition and abdominal pain since             15  days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic until 1 month ago then had c/o fever  high grade with chills which is intermittent, no diurnal variation and associated with burning micturition, dark urine 

Yellowish discoloration of eyes, vomitings, loss of appetite , generalized weakness, weight loss of 3 kg since 1 month.

C/o cough which is productive with whitish sputum, thick consistency, mucoid associated SOB grade 2 and wheeze since 1 month aggravated on exposure to cold &dust.

C/o indigestion of food

PAST HISTORY

He is known case of Asthma since 20 years

On inhaler Salbutamol 200mcg

N/k/c/o DM, HTN, TB, epilepsy

Personal history:

Patient is occasional alcoholic, stopped since 1 month, consumes 4 -5beedi per day since 40 years stopped 2 months back.

GENERAL EXAMINATION

Patient is conscious coherent cooperative moderately built and nourished 

Icterus present 

No Pallor Clubbing Cyanosis Edema 

Vitals : 

PR : 76 bpm

BP : 130/80 mmHg 

RR : 20 CPM

Temperature : 98.4f

Spo2 : 98 %

SYSTEMIC EXAMINATION

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, VBS

B/l fine crepts present MA IAA

Rhonci  B/l ICA, MA

shape of the chest: normal

trachea appears to be central

Per abdomen: soft, non tender

Depigmented skin lesions over the hands since 1 year

 

INVESTIGATIONS

Chest x-ray 

ECG

USG 

2D echo

TREATMENT 

Inj. Optineuron 1 ampoule in 100ml ns iv od

Tab. Amoxiclav 625mg po bd

Tab. Udiliv 150 mg po bd

Syp. Lactulose 15ml po tid

Nen duolin 6th hrly

Tab pcm 650 mg po sos