Final exam long case 1902102072

69 year old male patient with breathlessness and cough with sputum 
This is an online e log book to discuss our patient deidentified health data shared after taking his / her or gaurdian signature on 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 problems with collective current besevidence based inputs. This e log book also reflects my patient - centered online learning portfolio and your valuable inputs on the comment box. 
Cheif complaint 
Patient complains of breathlessness since 4days  and cough since 3days. 
History of present illness 
Patient was apparently asymptomatic 5 years back Patient complains of similar history in past. 
Admission to  Hospital twice in 2018 and 2021 and diagnosed as acute exacerbation of asthma with bronchiectasis. 
Pneumococcal vaccine taken on 19-10-21 
Influenza vaccine on 20-10-21
Usage of inhaler formonide,  with metred dose inhaler with spacer from 2 years and stopped since 1 month. 
Patient was apparently asymptomatic 4 days back then he developed breathlessness with gradual onset grade 2-3 associated with chest tightness ,wheeze , seasonal variation, aggrevated on cool air and dust. 
Cough with sputum since 3 days ,  mucopurulent, non blood stained, not foul smelling, no seasonal variation, more during night time, aggrevated on cold exposure. 
History of allergy with cough, watery eyes on exposure to dust. 
No history of fever, palpitations, haemoptysis, chest pain, weight loss, loss of appetite, burning micturation. 
History of past illness 

History of diabetes mellitus on medication 
No History of TB, cad, epilepsy , hypertension. 
Personal history 
Married 
Occupation - farmer 
Diet - mixed 
Bowel - regular 
Appetite - normal
Micturation- normal
Allergies- dust , cold air 
Addiction - toddy occasionally
 
No known family history

General examination 
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, malnutrition, dehydration, edema of feet. 
Vitals
Temp- afebrile 
Pulse rate - 110/min
Respiration - 34/min
Bp-110/90mm of hg
Grbs - 98%
Spo2- 90% at right atrial litres of o2
Systemic examination 
Cvs
No thrills 
Cardiac sounds s1s2 heard 
No cardiac murmurs
Respiratory examination
Inspection 
Shape - barrel shape chest 
Trail sign absent 
Accessory muscles of respiration being used 
Supraclavicular hollowness present 
No infraclavicular hollowness
No crowding of rib, drooping of shoulder, wasting of muscles
Spinoscapular distance equal on both sides
Chest movements equal on both sides
Apical impulse not seen
No kyphosis, scoliosis
No sinuses, scars, engorged veins with pulsations
Palpation 
All inspectort findings are confirmed 
Apex beat palpable at left 5th ICS, 1.25 CM medial to mid clavicular line
Measurements
Ap diameter 27cm
Transverse 27 CM
Chest circumference inspiration 94cm
Expiration 92cm
Hemithorax inspiration 46cm
Hemithorax expiration 44cm
Percussion
Direct resonance in clavicle and manubrium
Indirect resonance in all areas
                              Right       left 
Supraclavicular         R            R
Infraclavicular            R           R
Mammary                   R            R
Axillary                        R            R
Infraaxillary                R             R
Suprascapular           R              R
Interscapular             R              R
Infrascapular              R             R
Auscultation
Bilateral crebs seen in infraaxillary, mammary
, infra scapular 
Bilateral rhonci seen in interscapular, mammary
Supraclavicular      normal vesicular breath sounds              nvbs 
Infraclavicular     nvbs      nvbs 
Mammary            nvbs    nvbs 
Mammary            nvbs    nvbs 
Axillary                nvbs     nvbs 
Infraaxillary        nvbs     nvbs 
Suprascapular    nvbs    nvbs 
Interscapular      nvbs    nvbs 
Infrascapular      nvbs    nvbs 
Abdomen
Inspection
Shape - normal
No distension
All quadrants moving equally with respiration
Umblicus is central and inverted 
Skin over abdomen is normal
No visible scars 
Palpation
Liver spleen not palpable
Cns
Patient is conscious
Speech normal
No kernings sign, neck stiffness
Motor and sensory systems normal
Provisional diagnosis
Acute exacerbation of broncial asthma with bronchiectasis
Investigation
Cbp, lft, rft, 2d echo, x ray, sputum cbnaat, afb, fs, 
Treatment
Tab ceftriaxone 1mg iv bd 
Tab mucinac 600mg po tid 
Syrup ascoril 1tsp po tid
Neb mucomist 8th hourly 
Neb duoline 6th hourly 
Neb budicart 8th hourly 
Inj pan 40mg
19-1-23
20-1-23
















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