62 year old Male with shortness of breath and generalised weakness

 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

Name:M.Srilekha(intern)

Chief complaints:

Generalised weakness since 7 years 

Shoulder pain since 2016

Shortness of breath since 5-6 months 

lower back pain since 2 months 

History of presenting illness: 

Patient was apparently normal in 2011 then he had an heart attack for which PTCA was done 

Later he developed generalised weakness from 7 years 

then he developed shortness of breath Since 5-6 months  insidious in onset ,gradually progressing to NHYA grade 2 currently.Aggravated on climbing stairs ,lifting heavy weights . No h/o cough, palpitations, no h/o chest pain, no h/o fever. No h/o decreased urine urine output No h/o pedal edema

On and off back pain which is of pricking type radiating to b/l shoulder and lower back since 6 months relieved on medication.

No h/o decreased range of movements

No h/o trauma

No localised swelling seen

Past history: 

PTCA done in 2011

Not a k/c/o hypertension diabetes epilepsy tuberculosis thyroid disorders 

H/o malignant malaria 20 years back

Personal history:

Appetite: decreased

Sleep adequate

Bowel and bladder regular 

Habits :

Alcohol: used to drink regularly from 2007-2010 then he had heart attack in 2010 so stopped taking alcohol from 2010-2020,now takes occasionally 60ml/day

Tobacco:stopped 10 years back used to smoke 2-4 beedis/day

Family history:

Oral cancer for grand mother

General examination:

 patient is conscious coherent and cooperative well oriented to time place and person 

No pallor icterus cyanosis clubbing lymphadenopathy edema

Central obesity 

Vitals:

PR:60bpm

BP:120/90

RR:16com

SpO2:98%

GRBS:

CVS:

S1,S2 +

No added murmurs

JVP not elevated 

RS:

Inspection:

 b/l symmetrical chest both sides moving equally with respiration 

Trachea central in position 

Auscultation:

BAE + normal vesicular breath sounds heard

Per abdomen:

Soft non tender 

No organomegaly

Investigations:

2D echo 

Eccentric TR,mild MR AR TR with PAH

Mild global hypokinesia no MS AS sclerotic AV

Fair to good LV function 

Diastolic dysfunction + NO PE

ECG:

Vitals before 6 min walk test :

PR:70 bpm 

BP:120/70 mmHg 

RR:14cpm

Vitals after 6 min walk:

PR:80bpm

BP:110/70 mmHg 

RR:16 cpm 

ECG after 6 min walk test :

Glycated haemoglobin:

RFT:

LFT:

PLSB:

Provisional diagnosis:

SOB under evaluation 

Medicines:

Since 6 months 

Since 6 months

Since 12 years for acidity

From 2011

On day-1: investigations were sent and 2D echo, 6 min walk ECG were done 

Day-2: ophthalmologist referral  i/v/o refractory error

Advise : regular use of spectacles 

Day-3: X-ray si joint ap view with ls spine lateral view was taken as patient complained lower back pain

Discharge summary:

Admission date:15/2/23

Discharge date:18/2/23

Diagnosis:

CAD CCF

Low back ache due to lumbo sacral strain

Chief complaints:

62 year old Male cake to the opd with complaints of Generalised weakness since 7 years Shoulder pain since 2016,Shortness of breath since 5-6 months,Lower back pain since 2 months 

HOPI:

Patient was apparently normal in 2011 then he had an heart attack for which PTCA was done ,Later he developed generalised weakness from 7 years ,then he developed shortness of breath Since 5-6 months  insidious in onset ,gradually progressing to NHYA grade 2 currently.Aggravated on climbing stairs ,lifting heavy weights . No h/o cough, palpitations, no h/o chest pain, no h/o fever. No h/o decreased urine urine output No h/o pedal edema,On and off back pain which is of pricking type radiating to b/l shoulder and lower back since 6 months relieved on medication.No h/o decreased range of movements,No h/o trauma,No localised swelling seen

Past history:

PTCA done in 2011

Not a k/c/o hypertension diabetes epilepsy tuberculosis thyroid disorders ,H/o malignant malaria 20 years back

Personal history:

Appetite decreased 

Sleep adequate

Bowel and bladder regular 

Habits :

Alcohol: used to drink regularly from 2007-2010 then he had heart attack in 2010 so stopped taking alcohol from 2010-2020 ,now takes occasionally 60ml/day

Tobacco:stopped 10 years back used to smoke 2-4 beedis/day

Family history: oral cancer for grand mother

General examination: patient is conscious coherent and cooperative well oriented to time place and person 

No pallor icterus cyanosis clubbing lymphadenopathy edema

Vitals:

PR:60bpm

BP:120/90

RR:16com

SpO2:98%

CVS:S1,S2 +,No added murmurs,JVP not elevated 

Respiratory system:

Inspection: b/l symmetrical chest both sides moving equally with respiration ,Trachea central in position 

Auscultation:BAE + normal vesicular breath sounds heard

Per abdomen:Soft non tender ,No organomegaly

Ophthalmology referral on 16/2/23 I/v/o refractory error and their advise followed

 impression:Normal anterior segment

VA- right eye 6/36-6/12

        Left eye 6/24-6/9

AR-right 1.25 SPH 6/6 0.50 CYL X 106

       Left 1.00 SPH

RE:1.25 SPH

LE:1.00 SPH 6/6

N.V-BE 3+ spherical 

Advice: regular use of spectacles 

Investigations:

2D echo:Eccentric TR,mild MR AR TR with PAH

Mild global hypokinesia no MS AS sclerotic AV

Fair to good LV function,Diastolic dysfunction + NO PE

6 min walk test:

 Vitals before 6 min walk test :

PR:70 bpm 

BP:120/70 mmHg 

RR:14cpm

Vitals after 6 min walk:

PR:80bpm

BP:110/70 mmHg 

RR:16 cpm 

HbA1c:6.4%

Treatment given:

T.TRIMETHAZINE 60MG po/odx x 3days

T.SACUBITRIL +VALSARTAN SODIUM 50MG half tablet po/od x3 days

T.OMEPRAZOLE 20 mg po/od x 3 days

T.CLOPITAB po/od x 3 days 

Advise at discharge:

T.SACUBITRIL +VALSARTAN SODIUM 50MG half tablet po/od

T.CLOPITAB po/od

FUROSEMIDE+SPIRINOLACTONE weekly once po/od

Follow up:

Review sos to GM OPD