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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Date : 9th Feb 2023
Name : D.Santhosh (Internee)
CHEIF COMPLAINTS :
41year old male came to the opd with cheif complaints of,
Breathlessness since 4 days
Dry cough since 4 days
Headache since 4 days
HISTORY OF PRESENTING ILLNESS :
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 ( gradeI ).
4 days back he complained of breathlessness which is intially of gradeI progressed to grade II (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
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: 
CUE:
RFT:
HEMOGRAM:
ECG:
Chest xray:
X ray LS Spine
Lateral view
AP View
X Ray 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. PREGABALIN -NT PO/OD
TAB. PULMOCLEAR PO/BD
TAB. MONTEK-LC PO/HS
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