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

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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