A 58YR OLD M C/O B/L NASAL OBSTRUCTION

LEARNER REPORT
"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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comments box.


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 A DIAGNOSIS AND TREATMENT PLAN.


A 58YR OLD M PT. C/O  B/L NASAL OBSTRUCTION SINCE 3YRS . PT WAS APPARENTLY ASYMPTOMATIC 3YRS BACK THEN HE DEVELOPED NASAL OBSTRUCTION WHICH WAS INCIDIOUS IN ONSET GRADUALLY PROGRESSIVE , INTERMITTENT  AND AGGRAVATED ON EXPOSURE TO COLD  C/O BOUTS OF SNEEZING ON EXPOSURE TO COLD . IT WAS AGGRAVATED ON ON EARLY MORNINGS AND RELIEVED ON MEDICATION THAT IS FLUTICOZONE. 

NO H/O TRAUMA TO NOSE , BLEEDING FROM THE NOSE 
NO H/O HEADACHE  , FACIAL HEAVINESS , POST NASAL DRIP 

H/ O - 
USE OF FLUTICOZONE NASAL SPRAY SINCE
 2 YRS 

PAST HISTORY - 
K/C/ O HTN SINCE 2 YRS AND ON MEDICATION TELMA 20MG
N/K/C/O DM , THYROID 

FAMILY HISTORY - 
NO SIGNIFICANT FAMILY HISTORY

DRUG HISTORY - H/ O FLUTICOZONE NASAL SPRAY 
ON MEDICATION FOR HTN  TELMA 20MG

PERSONAL HISTORY 
DIET - MIXED 
APPETITE - NORMAL
BOWEL MOVEMENTS - REGULAR
BLADDER - BPH 
ADDICTIONS

GENERAL EXAMINATION : PATIENT IS CONSCIOUS ,COHERRENT, CO OPERATIVE AND WELL ORIENTED TO HIS SURROUNDINGS.
HE IS MODERATELY BUILT AND NOURISHED.
NO PALLOR ,NO CYANOSIS, NO ICTERUS, NO LYMPHADENOPATHY. 

VITALS:. TEMPERATURE: AFEBRILE. 
PULSE RATE: 98 BEATS / MIN.
 RESPIRATORY RATE: 19 CYCLES / MIN.
 BP: 130/80 MMHG
SPO2: 99 
GRBS - 112 MG/DL

SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD

DVL REFERRAL - POST INFLAMMATORY HYPERPIGMENTATION 
1) PHYSIOGEL LOTION 
2) TAB .DAZIT 5MG OD X 2 WEEKS 
3)OINT. TACROLIMUS 0.1% OD x 2 WEEKS
4) MOISTUREX SOAP


ENT REFERRAL - DNS , INFERIOR TURBINATE HYPERTROPHY
1) STEAM INHALATION 
2) DUANASE NASAL SPRAY 2 PUFF / BD X 15 DAYS 

UROLOGY REFERRAL 
I/V/O -  K/C/O Prostatomegaly ( BPH ) Since 2019

Rx
1) TAB. TAMSILOSIN 

USG on 26/3/22
 

S
B/L NASAL OBSTRUCTION

O
VITALS
TEMP - AFEBRILE
BP - 130/90 MMHG
PR - 86 BPM
RR -  15 CPM
CVS - S1 S2 HEARD
RS - BAE +

A 
DNS , INFERIOR TURBINATE HYPERTROPHY

P
TREATMENT
1) DUANASE NASAL SPRAY
2) TAB . DAZIT 5MG OD
3) OINT. TACROLIMUS
4 ) PHYSIOGEL LOTION


NIGHT MONITORING 
- NO HYPOXIC EPISODES 
- SNORING EPISODES +







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