73 yr old male with giddiness and SOB
Manvi Sharma
Batch of 2018
Date: 4/3/22
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A 73 YEAR OLD MALE PATIENT WHO IS A PRIEST CAME TO THE OPD WITH CHIEF COMPLAINTS OF "SHORTNESS OF BREATH SINCE 1 YR, GIDDINESS AND NECK PAIN SINCE 7-8 MONTHS, AND DECREASED URINE OUTPUT SINCE 8 MONTHS."
HOPI - THE PATIENT WAS APPARENTLY ASYMPTOMATIC ONE YEAR BACK, WHEN HE WENT TO THE LOCAL HOSPITAL WITH COMPLAINTS OF HEART BURN AND RIGHT SIDED CHEST PAIN, WHERE HE GOT DIAGNOSED WITH HYPERTENSION.HE WAS GIVEN RAZO D AND PUT ON TELMA 40. SINCE 7-8 MONTHS HE IS COMPLAINING OF GIDDINESS WHILE WALKING AND SQUATTING IN WASHROOM WHICH SUBSIDES ON SITTING, FOR WHICH HE WAS GIVEN TAB STEMETIL,BUT IT DID NOT HELP. GIDDINESS IS ASSOCIATED WITH NECK PAIN ON RIGHT SIDE( MORE ON UPWARD MOVEMENT OF NECK) AND HEADACHE (DIFFUSE TYPE). HE WENT TO THE LOCAL HOSPITAL WHERE THEY RAN SOME BASIC INVESTIGSTIONS. HIS ECG SHOWED ST-T CHANGES IN LEAD 3 AND avF AND RBB BLOCK. HIS CHEST XRAY SHOWED COPD AND XRAY SPINE SHOWED SPONDYLITIC CHANGES. 2D ECHO SHOWED MILD LVH AND SINCE THEN HE WAS PUT ON ECOSPRIN 75. HE WAS USING FORACORT INHALER ( BUDESONIDE AND FORMETEROL) BUT WAS NON-COMPLIANT. SHORTNESS OF BREATH IS PRESENT ON WALKING FOR SHORT DISTANCES ITSELF AND IS RELIEVED ON TAKING REST(NYHA CLASS - 3). HE ALSO COMPLAINTS OF HEAVY BREATHING IN MORNING AFTER GETTING UP. URINE FLOW IS MARKEDLY REDUCED AND THE STREAM OF URINE IS DISCONTINUOUS(?enlarged prostate) TAB FLODART PLUS (TAMSULOSIN)GIVEN AT BEDTIME FOR THIS. PATIENT ALSO COMPLAINTS OF DECREASED HEARING IN RT EAR SINCE 1 MONTH WHICH HE NOTICED WHILE TALKING ON THE PHONE.
PAST HISTORY - HE IS A K/C/O HTN SINCE 1YR AND WAS PUT ON TELMESARTAN AND ASPIRIN MEDICATION.
HE UNDERWENT FOLLOWING SURGERIES IN THE PAST : GALL STONES REMOVAL 7 TO 8 YRS BACK AND PILES OPERATION 6 TO 7 YRS BACK.
PERSONAL HISTORY -
APPETITE - NORMAL
DIET - VEGETARIAN
B&B MOVEMENTS - DECREASED URINE FLOW AND DISCONTINUOUS STREAM OF URINE
SLEEP - ADEQUATE
ADDICTIONS - CONSUMED ALCOHOL AND SMOKED CIGARETTES IN CHILDHOOD BUT STOPPED IT SINCE 40 YEARS. HE EATS PAAN CONTAINING TOBACCO REGULARLY ABOUT 10-15 PER DAY.
HIS DAILY ROUTINE COMPRISED OF GOING TO THE TEMPLE FROM MORNING TO EVENING. HOWEVER SINCE THE PAST ONE YEAR HE HAS STOPPED WORKING AND TAKES REST AT HOME.
FAMILY HISTORY - NOT SIGNIFICANT
VITALS -
TEMP - AFEBRILE
BP - 140/90 mm Hg
HR - 90 bpm
RR - 16 cpm
SPO2 - 99%
GRBS - 154 mg/dl
GENERAL PHYSICAL EXAMINATION -
THE PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE AND WELL-ORIENTED TO TIME, PLACE AND PERSON.
BUILT - OBESE (ABDOMINAL OBESITY)
PALLOR PRESENT
KOLIONYCHIA PRESENT
B/L PITTING TYPE OF EDEMA SEEN BELOW KNEE
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
SYSTEMIC EXAMINATION -
CVS : S1,S2 HEARD
RS : NVBS HEARD
GIT : SOFT, NON TENDER
CNS : NAD
INVESTIGATIONS -
HEMOGRAM - IMPRESSION : MICROCYTIC HYPOCHROMIC ANEMIA
LFT -
TB - 1.14mg/dl
DB - 0.42mg/dl
AST - 20 units
ALT - 19 units
ALP - 212 units
TP - 6.3g/dl
ALB - 3.6g/dl
A/G RATIO - 1.4
RFT -
BLOOD UREA - 31mg/dl
SERUM CREATININE - 1.2 mg/dl
CXR -
ECG -
2D ECHO -
Plan -
Urology follow up (BPH?)
Advice - lifestyle modification changes
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