October 17,2023 60 with DOV since 4 months

Hi ,I am P.Kathyayani, 5th sem medical student. This is an online elog book to discuss our patient’s health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 60 Male resident of suryapet came to OPD with chief Complaints of diminution of vision of both eyes since 3-4 months.

History of presentinng illness:
Patient was apparently asymptomatic 3 months ago then developed DOV in both eyes which is insidious in onset and gradually progressive.
C/o breathlessness grade 1 MMRC+ not associated with wheeze . Aggravated on exertion.
 No h/o any itching of eye,redness, watering,trauma.
No c/o fever,chest pain,cough,hemoptysis,palpitations, orthopena,PND,pedal edema, decreased urine output.

Past history:
K/c/o asthma since 10 years on Ipratropium bromide and Levosulphate, Rotacap inhalers 
H/o pulmonary TB 20 years ago
Not k/c/o HTN,DM,Epilepsy,CAD,CVD, Thyroid
 
Personal history:
Married 
Mixed diet
Appetite normal
Sleep adequate 
Bowel and bladder movements regular
Micturation normal
No known allergies
No addictions 

Family History: not significant 

Drug History:
On Ipratropium bromide and levosalbutamol sulphate rotacap inhalers -for asthma since 10 years.

General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative
- well oriented to time, place and person.
- well built and moderately nourished
- no pallor 
- no icterus
- no cyanosis 
- no clubbing of fingers 
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- no dehydration 

Vitals:
- Temperature: afebrile
-BP:150/90 mm Hg
-Pulse:76 beats/min
- RR:16 cycles/min


Systemic Examination:
CVS:
No thrills
S1S2 sounds heard 
No cardiac murmurs 

RESPIRATORY SYSTEM:
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical 
- respiratory movements appear equal on both sides and of thoracoabdominal type
Position of trachea-central 
Vesicular breath sounds heard 
No dyspnea 
Wheeze +in bilateral ISA,IAA.

ABDOMEN:
Shape of the abdomen-scaphoid 
No tenderness 
No palpable masses
Normal hernial orifices 
No free fluid 
No bruits
Non palpable liver
Non Palpable spleen
No Bowel sounds heard

CNS:
Level of consciousness- conscious
Speech- normal
Signs of meningeal irritation 
         stiffness of neck :no
          Kerning's sign:no
Cranial nerves,motor system, sensory system-normal

Reflexes
           Biceps Triceps supinator knee ankle 
Right       2+.     2+           2+         2+       2+    
Left         2+.      2+          2+       2+.         2+

Cerebellar signs:
- finger nose in coordination: not seen 
- knee heel in coordination: not seen

Investigations: 
 Ocular examination 



Hemogram:
Hb:13.0
TLC:10,700
N/L/E/M: 73/14/3/10
PLT:3.26

RFT:
BU:20
SC:0.8
Na+:135
K+:4.5
Cl-:103

LFT:
TB:0.64
PB:0.19
SGOT:122
SGPT:138
ALP:291
TP:6.8
Alb:4.2
A/G:1.66

2D ECHO :
     EF:6.3
 Concentric LVH,No RWMA
IVC:1.12 cm collapsing 
RVSP:35 mm Hg 




ECG:


Serology:
Negative 

CXR PA view:
Right unilateral fibrosis

RS:
BAE+,VBS+,
BL Rhonchi +,inter SA,Infra SA,
IAA,AA,ICA,MA.

Provisional Diagnosis:
-Left eye -senile mature cataract associated with denovo hypertension 
-Known case of bronchial asthma since 10 years ,on medication. 
-Asthma/COPD?(PFTB).

Medication:
E/D CIPLOX QID
TAB.NICARDIA QID

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