General medicine case discussion

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending     clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   

Feb 9th, 2023.

K. Tejarshini (Intern) 

A 41year old male came to the opd with complaints of, 

Breathlessness since 4days

Dry cough since 4days

Headache since 4days

Patient is apparently asymptomatic 10-12years back then he complained of severe breathlessness (grade4) then on RMP advise he used inhalers for 1-2months and symptoms get relieved,then he stopped using inhaler. 

Since then he had episodes of breathlessness of mild grade of grade1. 

 4days back he complained of breathlessness which is intially of grade 1 progressed to grade 2 (acc. to MMRC grading) since 2days.breathlessness increased after intake of food and relieved after sometime of rest. 

H/O wheeze present. 

No H/O chest pain, palpitations, Orthopnea, PND. 

He also complained of cough which is non-productive , get aggravated in supine position. 

Head ache since 4days in the frontal region. 

H/O Tingling sensation of both upper and lowerlimbs present. 

C/O neck pains which get aggravated on supine position

Patient also complained of low backache. 

No H/O fever, abdominal pain, vomitings. 

Past History:

K/C/O HTN since 1month and on unknown medication

N/K/C/O DM, ASTHMA, EPILEPSY, TB, CVA, CAD, THYROID DISORDERS. 

Personal History:

Appetite:Normal

Diet:Mixed 

Bowel and bladder habits :regular

Sleep:Adequate

Addictions:No

FAMILY HISTORY:

No similar complaints in the past

GENERAL EXAMINATION:

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

He is conscious, coherent and cooperative, moderately built and nourished.

No signs of pallor, edema, icterus, cyanosis, clubbing, Generalized lymphadenopathy.

VITALS:

Temperature : 98.4F
Pulse rate :96 beats/min
BP : 110/80 mm Hg
RR : 18cpm

RESPIRATORY SYSTEM EXAMINATION:

INSPECTION:

Shape of chest is elliptical, 
B/L symmetrical chest,
Trachea appears in central position,
Expansion of chest-Normal on both sides

Movements of chest Normal on both sides
Use of Accessory muscles is not present.

PALPATION:
No local rise of temperature,non tender
trachea is central
Measurement:
AP: 26cm
Transverse:30cm
Right hemithorax:50cm
left hemithorax:49cm
Circumferential:100cm
Tactile vocal fremitus:Normal on both left and rightside

PERCUSSION: Resonant note heard 

AUSCULTATION:

Wheeze heard in B/L infraclavicular, mammary, infra-mammary, supra scapular, infra scapular, inter scapular areas. 

CVS:S1S2+ , No murmurs

P/A:Soft, Non-Tender

CNS:NAD

INVESTIGATIONS:

LFT:

SEROLOGY:

CUE:

RFT:

HEMOGRAM:

ECG:

Chest xray:

PFT:

X-ray of LS Spine:

Lateral view:

AP View:

X-ray of Cervical Spine:

AP View:

Lateral View:

DIAGNOSIS:

? BRONCHIAL ASTHMA With HYPERTENSION SINCE 1MONTH, CERVICAL MYELOPATHY WITH LUMBAR CANAL STENOSIS. 

TREATMENT:

NEBULISATION WITH DUOLIN 8TH HOURLY

                                        BUDECORT 12TH HOURLY

TAB. TELMA 40MG/PO/OD

CAP. PAN-D PO/OD

TAB. ULTRACET 1/2TAB PO/BD

TAB. MTV PO/OD

TAB. PREGABA-NT PO/OD

TAB. PULMOCLEAR PO/BD

TAB. MONTEK-LC PO/HS