GM case of a 73 year male

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 histoty, clinical findings, investigations and come up with a diagnosis and treatment plan.

Case:

A 73 year male who is a resident of gonaboynapally, came to OPD with 

Chief Complaints:

Breathlessness since 10 days.

Epigastric pain since 4 days.

History of present illness: 

Patient was asymptomatic 12years back and developed cough for which he went to hospital and diagnosed with tuberculosis.4years back patient had developed swelling in his scrotum and underwent hydrocele surgery. Since 2 months patient is having breathlessness on and off for which he used to go near by RMP and use medication and used to drink alcohol to get sleep. 10 days back patient had developed severe shortness of breath and got admitted in area govt. hospital and was diagnosed with tuberculosis (CBNAAT) on 3/11/22. SOB of grade IV, gradual chronic onset, associated with cough(productive and white in color), no relieving factors.

History of past illness:

Not known case of DM, HTN, CAD, asthma.

Treatment history:

12 years back took TB treatment for 6 months.

Underwent hydrocele surgery 3 years ago.

Personal history:

Diet: mixed

Appetite: lost since 10 days.

Sleep: inadequate

Bowel and bladder: irregular

Addiction:

Drinks alcohol regularly since 40years.

Smoked for 30 years quitted 12 years back.

Family history: not significant.

General Examination: 

Patient is conscious, coherent and cooperative, well oriented to time, place and person.

Pallor: No

Icterus: No

Cyanosis: No

Clubbing of fingers: Yes

Lymphadenopathy: No

Pedal oedema: No

Vitals:

BP: 140/100

Pulse rate: 127 per min.

Respiratory rate: 40 per min.

SpO2: 97%

GRBS: 128 mg/dl

Systemic Examination:

CVS: S1,S2 are heard 

         No murmurs.

Respiratory system:

Inspection:

Palpation: 

Percussion:

Auscultation:

Abdomen:

Inspection: no scars seen.

Palpation: tenderness in epigastric region.

Auscultation: Bowel sounds heard.

CNS Examination:

Cranial nerves intact.

Provisional diagnosis:

- Pulmonary tuberculosis.

- Anterior wall MI.

- HFrEF

- Non oliguric renal AKI

Clinical images:

Investigations:

Blood urea level:

HIV test:

Serum Electrolytes:

LFT:

Serum Creatinine:

ECG:

Final diagnosis:

- Pulmonary TB

- Anterior wall MI.