Case Study 6
October 25th , 2021
"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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 inputs on the comment box
A 70 year old male , farmer by occupation , came
with chief complaints of cough since 10 days ,
shortness of breath since 10 days , decreased
urine output since 1 week , facial puffiness since 1
week and bilateral pedal edema since 1 week .
HISTORY OF PRESENT ILLNESS
The patient was apparently assymptomatic 10 years
back then he developed chest pain and palpitations
for which angiogram was done. 2 years back
patient developed cough, which was productive ,
sputum - whistish in colour, non foul smelling , not
blood tinged , associated with shortness of breath
grade 2 , not associated with orthopnea , PND.
Patient was diagnosed with bronchial asthma 2
years back and was on inhalers since then.
C/o low grade fever (intermittent) since 15 days
associated with chills , subsided on medication.
PAST HISTORY
Known case of Diabetes mellitus since 2 years using
Tab.amlogen-AT
Hypertension since 10 years and using Tab.Glimi
M1
No known case of Tuberculosis
PERSONAL HISTORY
Diet - Mixed
Appetite - Normal
Bowel and bladder movements - regular
Sleep - Adequate
Habbits - Smoking since 50 years (7 packs /day )
and he stopped now since 2 years
Alcoholic since 40 years ( occasional )
ON GENERAL EXAMINATION
Patient is conscious , coherent and cooperative
Moderately built and well nourished
No pallor , icterus , cyanosis, clubbing
lymphadenopathy.
Vitals-
Temperature - 98.5
PR- 112 bpm
BP- 140/80 mm hg
Rr- 20 cpm
Spo2 - 98% at ra
Grbs- 112 mg/dl
SYSTEMIC EXAMINATION
CVS :
No thrills
S1 S2 heard
No murmurs
RESPIRATORY SYSTEM :
No dyspnea
Wheezing
Trachea is in central position
Vesicular breath sounds heard
PER ABDOMEN :
Scaphoid in shape
Not tender
No palpable mass
No free fluid
Bowel sounds heard
CNS :
No focal neurological deficits
PROVISIONAL DIAGNOSIS
Viral pyrexia under evaluation with chronic
bronchial asthma with pneumoconiosis
(occupational lung disease).
Comments
Post a Comment