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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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
9-March-2022
A 80 year old male came to OPD with
Shortness of breath since 15 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 10 days back and then he developed Shortness of breath grade II, which was insidious in onset, not associated with Orthopnea or paroxysmal nocturnal dyspnea. It was relieved on taking bronchodilators.
From 7:00pm, patient developed sudden onset of Shortness of Breath (grade IV) and was brought to our hospital. He stopped taking bronchodilators 2 days back.
No history of fever, chest pain, palpitations or pedal edema.
PAST HISTORY
Patient had similar episodes 2 to 3 times a month since past 3 years.
Medication being taken-
*Ipratropium bromide and levosalbutamol 200 MDF ( 3 times a week)
*Theophylline(23 mg) and etophylline (77 mg) BD
* Montek(10 mg) - LC (5 mg) BD
No H/o Diabetes, Hypertension, Leprosy, Tuberculosis, Coronary heart disease, Epilepsy.
PERSONAL HISTORY:
Diet : Mixed
Appetite : Normal
Sleep : Disturbed
Bowel and Bladder moments : Regular
Micturition : Normal
FAMILY HISTORY:
Not significant
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