63M came with c/o fever,cough,difficulty in breathing

Hi!! This is Vijaya ratna,9th semester medical student.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

A 63yr old male patient came with the complaints of fever,cough since 1 month and difficulty in breathing since 2 days

HOPI 

Patient was apparently asymptomatic 1 month back and then had fever intermittent in onset, low grade, associated with chills and rigors,no diurnal variations,no aggravating factors relieved on medication

C/o cough since one month associated with sputum sometimes 

C/o difficulty in breathing since 2 days

PAST HISTORY

K/C/O CAD Post PTCA status 8 yrs back 

K/C/O HTN since 3 months but not on any medication 

H/o blood transfusion 8 days back - 1 PRBC ,

N/K/C/O DM , CVA , Asthma , TB, Epilepsy

PERSONAL HISTORY 

Diet : mixed 

Appetite: normal 

Sleep : adequate 

Bowel and bladder : regular 

Addictions: 

Alcohol - used to consume alcohol stopped 15 yrs back 

H/o smoking + but stopped 15 yrs back 

FAMILY HISTORY

Not significant

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative

He is Ill built and malnourished

No signs of pallor,icterus,cyanosis,clubbing, lymphadenopathy,edema

VITALS

Temperature - 101 F @4pm

                      100 F @5pm 

                      98.7 @6pm 

BP

PR - 96bpm 

RR - 16cpm 

SYSTEMIC EXAMINATION 

CVS - S1 S2 heard,no murmurs

RS - BAE PRESENT NVBS HEARD

P/A -Soft , non tender 

CNS -NFND 

20/10/23

21/10/23

PROVISIONAL DIAGNOSIS

PYREXIA UNDER EVALUATION , HEART FAILURE (EF - 54%) SECONDARY TO CAD - S/P PTCA 8yrs back 

TREATMENT

IV fluids : UO + 30ml/hr 

Inj.NORADRENALINE (6ml/hr IV infusion ) increase /decrease according to BP - 0.16mg = 1 ml 

Tab. ROVASTATIN + CLOPIDOGREL PO/HS (75MG + 10 MG )