55Y M with SOB since 3 months ; fever since 1 month 26/10/23

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. 


Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.





This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.




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.



55 Y OLD MALE CAME TO MEDICINE OPD
C/O BREATHLESSNESS SINCE 3 MONTHS
FEVER SINCE 1 MONTH

HOPI- PT WAS APPARANTLY  ASSYMPTOMATIC  1 YEAR BACK AFTER WHICH HE STARTED DEVELOPING BREATHLESSNESS  ; GRADE 4 INCREASING ON ACTIVITY
NO H/O ORTHOPNEA; PND
H/O FEVER SINCE 1 MONTH ; LOW GRADE ASSOCIATED WITH GENERALISED BODY PAINS
H/O DRY COUGH SINCE 1 MONTH
NO H/O COLD
NO H/O SORE THROAT 
NO H/O CHEST PAIN; PALPITATIONS; EXCESSIVE SWEATING 
NO H/O BURNING MICTURITION; PAIN ABDOMEN, NAUSEA; VOMITING;

PAST H/O
H/O USAGE OF INHALER SINCE 1 YEAR
N/K/C/O DM; HTN
N/K/C/O CAD, CVA

PERSONAL H/O -
MIXED DIET
APPETITE LOST
BOWEL AND BLADDER - REGULAR
SLEEP- ADEQUATE 
ADDICTIONS-
TODDY- SINCE 40 YEARS OCCASIONAL 
STOPPED SINCE 2 TO 3 MONTHS
ALCOHOL - 
SINCE 1 YEAR OCCASIONAL
STOPPED SINCE 2 TO 3 MONTHS 

FAMILY H/O 
NOT SIGNIFICANT 

GENERAL PHYSICAL EXAMINATION 

PT IS CONSCIOUS COHERENT COOPERATIVE
MODERATELY BUILT AND NOURISHED 
NO SIGNS OF PALLOR; ICTERUS ; CYANOSIS; CLUBBING; KOILONYCHIA; GENERALISED LYMPHADENOPATHY PEDAL EDEMA

VITALS
TEMP- 98 F
BP- 120/80 MM OF HG
PR- 80 BPM
RR- 18 CPM
SPO2 - 98% RA

SYSTEMIC EXAMINATION-

CVS- S1; S2 HEARD
NO MURMORS

RS- NVBS+ BAE+

P/A-SOFT; NON TENDER; NO ORGANOMEGALY 

CNS- NORMAL

INVESTIGATIONS 


       

DIAGNOSIS :PULMONARY TUBERCULOSIS SECONDARY TO HIV 


TREATMENT 
1.TAB PCM 650 MG PO/TID
2.TAB MONTEK LC PO/BD
3.SYRUP- ASCORYL - D 10ML PO/TID


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