80 year old Male with shortness of breath

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINTS

A 80 yr old male resident of nakrekal , farmer by occupation presented to the OPD with complaints of 

Difficulty in breathing since 1 month 

Cough with sputum since 7 days 

CLINICAL FEATURES

CVS

Inspection

No visible heart pulsations

Palpation:

Apex beat at 6th intercoastal space

Auscultation: S1,s2 are heard

Rhythm regularly irregular

CLINICAL IMAGES

PROVISIONAL DIAGNOSIS

Dilated cardiomyopathy 

Bilateral pulmonary effusion

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 hourlyb, udecort - 5th hourly

Syrup Grillinctus, 10 ml