A 55year old with weakness of body

 This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

A 55year old came to hospital with chief complaints of weakness since 1 month which increased in last 5 days.

History of presenting illness:

Patient had joint pains since 6years , it was associated with fever. He has been taking Fabric 40 for that joint pains.

Cough since 2 years which was insidious in onset, gradually progressive, with sputum .

Sputum was pale coloured , filled 1/2 cup for whole  day , cough increased at night.

Fever since 1 month which was on and off , he used medication for fever.

Weakness of body started 1 month back when he took alcohol in excess amount and was not eating food properly. Weakness of body increased in last 5 days .

He has shortness of breath since 1 month grade 3 (mmrc grading)

 3 years ago he had decreased urine output and when he went to hospital he was diagnosed with chronic kidney disease. In last 3 years  hemodialysis was done for 10 times.

He is a known case of hypertension since 5 years and on medication.

Known case of diabetes since 3 years and on medication.

He was admitted twice in hospital for history of seizures 6years and 3years ago. No medication was used after seizure episode.

Personal history:

Appetite: decreased.

Sleep: disturbed due to cough.

Bowel and bladder:Normal.

Drinks alcohol everyday.

General examination:

Patient was conscious, coherent and cooperative.

Poorly built and nourished 

Pallor -present.

Icterus, Clubbing ,Cyanosis , lymphadenopathy ,edema - absent.

Vitals on admission:

Pulse :

Bp:

Respiratory rate:

Temperature:

Systemic examination:

Respiratory system:

Inspection:

Chest expansion decreased on left side.

Trachea in midline.

Supraclavicular and infraclavicular hollowing present.

Palpation:

Trachea in midline.

Chest expansion decreased on left side.

Vocal fremitus cant be done because patient is not cooperative.

Percussion:

  Supraclavicular, Infraclavicular , Mammary areas : hyper resonant on right side , Resonant on left side.

Other areas can't be done.

Auscultation:

Vesicular breath sounds on right side.

Tubular breath sounds heard on left side.

Central Nervous system examination:

Higher mental function intact.

Investigations:

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Treatment given:

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