80 year old male with shortness of breath

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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 to come up with a diagnosis and treatment plan.

An 80 year old man, residing in Nakrekal, farmer by occupation, came to OPD with chief complaints of -

Shortness of breath since 1 month

Cough with sputum since 7 days

History of presenting illness - 

Patient was apparently asymptomatic 4 years back, then he developed swelling on the right leg which was diagnosed as filariasis. The patient has not used any medication for filariasis.

Then he had an injury for his left leg 3 years ago, for which he had to undergo a surgery (rod and plate fixation).

Later he developed shortness of breath 1 months ago, which was insidious in onset, gradually progressing, aggravates on performing any physical activity, and not relieving with rest since the last seven days.

He also had decreased urine output since 20 days for which urethral stricture dilatation was done.

No history of burning micturition, fever and weight loss.

Past history -

The patient is not a known case of hypertension, diabetes, asthma, epilepsy, tuberculosis. 

H/o trauma in left leg treated by internal fixtures

H/o right leg swelling due to filariasis

No previous hospitalizations

Personal history -

The patient is an elderly male who was a farmer by occupation, refrained from going to the fields since 15 years.

His daily routine consists of -

Wakes up at 6 am

Do his daily chores

Minimal activity in the whole day.

Apettite - decreased

Diet - mixed

Bladder - decreased

Bowel - normal

Sleep - disturbed 

Addictions - Smoking - stopped 15 years ago

Alcohol - stopped 1yr ago

Family history - no relevant history

Treatment history - no treatment history

General examination - 

The patient was conscious, coherent, cooperative and well oriented to time, place and person.

He is well built and moderately nourished.

Pallor present

Edema of pitting type seen in both the legs of grade 3.

No signs of icterus, clubbing, cyanosis

Vitals :

Temperature - 98.6 F

Pulse rate - 80 bpm

Blood pressure - 130/90 mm Hg

Respiratory rate - 20 cpm

Spo2 - 96 %(room air)

Systemic examination :

CVS - 

On Inspection -

No visible heart pulsations

On palpation -

Apex beat at 6th intercoastal space

On Auscultation - 

S1, S2 are heard

Rhythm - regularly irregular

Respiratory system -

Inspection: 

Chest shape - normal

Breath movements - abdominal thoracic

Dysponea - present

Palpation: 

Trachea - central

Tactile vocal fremitus decreased in infra axillary and infra scapular regions

Percussion: 

Dull note in infra axillary and infra scapular regions

Auscultation : 

Coarse basal crepitations are heard in infra axillary and infra scapular area

 

Wheezing heard in mammary region

Vesicular breath sounds

Abdominal examination -

Shape : scaphoid

Tenderness : no

Free fluid : no

Liver : not palpable

Spleen : not palpable

CNS -

No focal neurological deficits

Investigations :

On 30/11/22,

On 1/12/22,

Ultrasound report - 

On 2/12/22,

On 3/12/22,

On 4/12/22, 

Treatment - 

Inj. Augmentin, 1.2 gm, IV, TID

Tab. Azithra, 500 mg, OD, Per oral

Tab. Pantop, 40 mg, OD, per oral

Tab. Met xl, 25 mg, OD, per oral

Tab. Montair LC, per oral

Tab. Ecospirin, 75 mg

Tab. Ultracet, per oral, QID

Tab. Lasix, 40 mg, BD

Neb. C duolin - 4th hourly

            budecort - 5th hourly

Syrup Grillinctus, 10 ml

Provisional diagnosis :

Dilated cardiac myopathy with bilateral pleural effusion

Anemia of chronic illness (?)