A 75 year old male with loose stools and chest pain
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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 is welcome.
This is a case of a 75 year old male who came to the opd with a chief complaint of loose stools and generalised weakness.
History of Presenting Illness:
Patient was apparently asymptomatic 10 years back. Then he developed coughing for more than 3 weeks and was diagnosed with tuberculosis. He took treatment for 6 months and then got cured.
The patient was fine after that other than an occasional fever or any other mild illness, he had no serious complaints.
Since one year, he said he has been coughing. It is usually dry but sometimes associated with very small quantities of mucus.
Then 4 months ago he developed wheezing and shortness of breath of grade 3/4. The patient described it as some sort of a high pitched sound in his throat. He went to a hospital and used some medication but he said it wasn’t effective.
Since 15 days, he has been frequently urinating. He urinates small quantities every 5-10 minutes.
Then on 27th June, he had 3-4 episodes of loose stools per day for 2 days which were non blood stained, watery of small quantity. He went to another hospital and took treatment and then came here after finding out he had low blood pressure.
On July 3rd, he complained of chest pain and epigastric pain radiating to his back. It was a piercing type of chest pain and increased on walking and inspiration and decreased on sitting. He also complained of feeling nauseas and bloated and he says he now feels constipated after coming here. He also says he feels breathless after eating or talking.
Insight about the patient:
Prior to being diagnosed with tuberculosis, the patient used to go to his fields and work there everyday. He grew paddy and raised cattle and goats. He stopped going out to work since 10 years and now stays at home. He regularly spends time with his children, grand children and great grandchildren and is a cheerful and active person.
He had a habit of smoking beedi for around 50 years but quit around 7-8 years ago when his physician advised him not too. He used to smoke almost 16-17 per day. He also occasionally consumed alcohol.
Daily routine:
The patient wakes up at 5 AM and freshens up. He has tea and if he feels like it he goes to his farm and checks upon the farm work. He has breakfast at around 9 am and then rests for some time. He has lunch at 1 pm and rests for an hour. In the evenings he spends time with his family or by himself or chats with the neighbours. He takes dinner at 8 pm and goes to bed.
Past history:
When he was about 20 years old, a bull rammed into his right knee, and since then he has been walking with a limp.
When he was 25 years old, he had an appendicectomy
No history of Diabetes, hypertension
Personal history:
Diet: mixed
Appetite: decreased
Sleep: has sleep disturbances since the past few days.
General examination
Patient is conscious, coherent and cooperative. Well oriented to time place and person.
Pallor: absent
Icterus: absent
Clubbing: present
Cyanosis: absent
Lymphadenopathy: absent
Edema: present
Vitals:
Temp: 93 F
BP 90/60
Heart rate 65 bpm
Resp Rate 18 /min
SpO2: 94%
GRBS: 98 mg/dl
3-7-22 no pedal edema 4-7-22 pitting type of pedal edema seen
RESPIRATORY SYSTEM-
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity hygiene not maintained. Tongue has fissures and looks dehydrated
Chest appears barrel shaped
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea appears central & Nipples are in 4th Intercoastal space
No dilated veins, scars, sinuses, visible pulsations.
Palpation:-
All inspiratory findings confirmed
Trachea is deviated to the right
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
MEASUREMENTS-
AP diameter- 9.7 inches on right side and 9.3 inches on left side
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