A 62 year with loss of appetite.

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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 come up with diagnosis and treatment plan.

A 62 year old male patient came to OPD for Dialysis.

History of presenting illness:

Patient was apparently  asymptomatic  one month back then he developed shortness of breath and loss of appetite.SOB is sudden in onset gradually progressive.After 20 days he had complaint of shortness of breath, fever and loss of appetite for which he went to private hospital  where he was told to have raised serum creatinine then he came to our hospital for dialysis.Fever was treated  outside in private hospital 5 days back.Vomitings since 2 days, 2-3 episodes per day, food and water as content ,non projectile.

 Past history:

He has history of fall 5 years ago and knee surgery was done and diagnosed with HTN and DM type 2 and he is on irregular medication.No history of asthma, tuberculosis, Thyroid disorders.

Personal history:

Diet :mixed

Appetite :decreased since 30 days

Sleep :adequate

B&B: regular

Addicitons:Beedi smoker from 2-3 years

General Examination:

He is concious coherent cooperative.

Pallor is present,icterus clubbing cyanosis lymphadenopathy pedal edema absent

Temperature- afebrile

Blood pressure 110/80

Pulse rate- 78 bpm

Respiratory rate- 15 cpm 

Systemic Examination

On inspection

Shape of chest :bilaterally symmetrical.

Movement of chest wall : symmetrical.

Palpation

Position of trachea :central

Symmetrical chest expansion

Percussion:

Resonance is heard bilaterally

Auscultation:

Normal vesicular breath sounds are heard

No wheeze

Abdomen:

Shape:scaphoid

No scars swellings are seen

On palpation:

Non tender, soft, liver spleen not palpable

On auscultation:

Bowel sounds heard

Investigations:

HRCT done on 12-02-2022