Case: 80 year old man with lower back pain and breathlessness

Neha Pradeep, MBBS 9th semester

Roll no: 99

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. 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 patients 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 comment box is welcome .

I’ve 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.

Case: 

A 72 year old man, came with complaints of breathlessness and cough since 20 days and lower back pain since 10 days. 

History of Presenting Illness: 

A 80 year old male patient, who was an agricultural worker until 4 years ago and is now unemployed, presented to the OPD on with chief complaints of 

1. shortness of breath since 20 days

2. cough since 20 days and

3. lower back pain since 10 days. 

Patient was apparently asymptomatic 20 days back, then he developed productive cough.

Sputum was white in color, non blood stained, non-foul smelling. No diurnal variation in sputum production was noticed. 

Cough was sudden in onset. No progression. Aggrevated on lying down and walking. Relieved on using medication given by local RMP. 

Fever with chills and rigor for 3 days before admission

Loose stools on Day 2 of admission, 3 episodes in a period of 6hours- watery in consistency 

Nausea present, since past 10 days.

This was associated with shortness of breath which was initially Grade IV but it subsided on treatment with medication from another hospital.

Patient started the treatment around 10 days ago. 

Patient complains of bilateral lower Back pain since the past 10 days. 

Type of pain- squeezing pain

No aggrevating or relieving factors 

Not progressive

Not Radiating 

Patient is unable to walk without support because of the lower back pain. 

PAST HISTORY

Patient has joint pains in both knee joints and wrist joints since the past 10 years and has been using analgesic medication given by local RMP- 1 tablet every two days since the past 10 years.

Patient has itching throughout the body since the past 1 year and has been using a lotion to control the itching, prescribed by local RMP everyday before taking a bath since the past 1 year.

 

Patient lost sight in the right eye around 50 years ago from a household accident. He was gathering and beating firewood to kindle a fire in his household and during that process. It was associated with bleeding from the eye and subsequent loss of vision in the entire right eye. 

Not a known case of Diabetes Mellitus, Hypertension, epilepsy, tuberculosis. 

PERSONAL HISTORY

Patient consumes a mixed diet. 

Sleep is adequate, until 20 days ago when he was not able to sleep well because of the SOB. He is able to sleep well after starting medication 10 days ago. 

Bowel and bladder movements are regular until day 2 of admission.

Addictions- 

Smoked bidi (5 per day) for 15 years. Stopped 20 years ago 

Drinks Toddy everyday since past 50 years. (500ml/day) 

No Allergies

General Examination:

Patient is conscious, cooperative and coherent. 

Thinly built and moderately nourished. 

Pallor: None 

Icterus: None 

Cyanosis: None 

Clubbing: None 

Lymphadenopathy: None

Edema: None 

Vitals- 

BP- 110/70 mmHg

Pulse- 65bpm

Respiratory Rate- 14 cpm

Temperature- afebrile 

Respiratory System: 

1) Inspection: 

Elliptical shaped chest

Bilaterally symmetrically, no unilateral bulge 

Subcoastal angle is 90° 

Trachea: midline

No visible apical pulse 

Trail sign: negative 

Carotid pulse is visible

Symmetrical movements 

No retraction, scars or sinuses

2) Palpation: 

No tracheal shift 

Apical Impulse: appreciated on the 5th ICS on midclavicular line 

ECG: 

HRCT:

Lab Reports: 

Fever Chart: