61YRS WITH K/C/O BRONCHIAL ASTHMA AND K/C/O CAD UNDERWENT S/P PTCA

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment

Chief complaints::
 
Patient came with c/o cough since 18months
Shortness of breath since 1yr
Chest tightness and epigastric pain since 1yr

History of present illness::

Patient was apparently asymptomatic 18months back then he developed  cough insidious in onset gradually progressive,dry, diurnal variation more during night 
Shortness of breath was insidious in onset ,
Progressive more during night and aggrevated during winter and rainy season associated with wheeze ,no pnd and orthopnea
No H/o fever ,vomitings,loose stools ,pain abdomen
C/o chest tightness while sitting
Pain in epigastric region insidious ,non progressing non radiating

Past history

K/c/o  CAD since 3years underwent surgery--PTCA
K/C/O HYPERTENSION SINCE 3YRS
K/C/O BRONCHIAL ASTHMA SINCE 3MONTHS
Not a K/c/o DM,CVA,epilepsy,TB

Family history::
 Not significant

Personal history::
 
Diet:mixed
Sleep ::   adequate
Appetite:: normal
Bowel and bladder:: regular
Addictions::alcoholic aince 30years( Takes 2 quaters of whisky daily)
Smoker since 30 yrs(20beedi /day)

General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

No pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
 No Edema 


Vitals

Temperature::98.3f
PR-68bpm
Bp-110/60 mmhg
RR--18cpm

Local examination::



Respiratory system::
Inspection::

B/L symmetrical 
Trachea appears to be central
Supraclavicular and infraclavicular hallowing absent
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles absent
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 5th ICS in mid clavicular line

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::

                                             RT.           LT .

Supraclavicular.         Resonant.    Resonant
Infraclavicular.           Resonant.     Resonanat
Mammary.                  Resonant.     Resonant
Axillary                        Resonant.      Resonant
Infraaxillary.                Resonant       Resonant
Suprascapular.           Resonant.      Resonant
Interscapular.             Resonant       Resonant
Infrascapular.             Resonant        Resonant

Auscultation::

 B/L air entry present
 On auscultation:: NVBS
Wheeze preswnt in b/l lower lobes


PER ABDOMEN::
Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
No Tenderness present
No palpable mass 
No free fluid
Liver not palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard:

Cardio vascular system:
Jvp -not raised
Apex beat felt in 5h ICS in mid clavicular line
S1s2 heard
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Chest xray PA view 
2d echo






https://youtu.be/M1-ZoKqSo_s





Provisional diagnosis::::
 Bronchial Asthma k/c/o CAD s/p PTCA 
K/c/o Hypertension

Treatment::
1.neb.budecort and duolin  8th hrly
2.Tab ecospirin gold po/od
3.Tab .cardace 1.25 po/od
4.Tab .mext xl 12.5 mg po/od
5.Tab .aldactone 25mg po/od
6.Tab. Angispan 2.5mg po/od





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