36 YR OLD MALE PATIENT WITH BREATHLESSNESS & DIFFICULTY IN SWALLOWING

Wednesday, January 12, 2022

36 YR OLD MALE PATIENT WITH BREATHLESSNESS & DIFFICULTY IN SWALLOWING

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Hyndavi Konakanchi, 8th semester

Roll no: 63

January 13 , 2022

A CASE DISCUSSION ON 36 YR OLD MALE PATIENT WITH BREATHLESSNESS & DIFFICULTY IN SWALLOWING

I've 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.

Following is the view of my case :

CASE PRESENTATION:

A 36 year old male patient who is a watchman in a govt. Hospital came to the casualty with the cheif complaints of breathlessness and difficulty in swallowing ( even saliva ) since 1 day

HISTORY OF PRESENTING ILLNESS :

Daily routine :

This patient who is watch man by occupation since 20 years, wakes up at 5 am in the morning and goes for a walk and have his breakfast around 8:30 am ( rice and curry ) — then he goes for covid duties ( like referring tests ) as his part time job since 2 years before that he used to stay at home — he will have his lunch at 1 pm — he will have tea at 5:30 pm — & goes for his watch man duty — will have dinner at around 8:30 pm and sleeps at 10 pm ( He takes sound sleep of 8 hrs )

He has good relationship with his family and friends

He was married 16 years ago and he had 2 girl childs

Patient was apparently asymptomatic before 2007 and then he developed breathlessness and difficulty of swallowing ( even saliva ) , following that he noticed swelling of uvula for which he went to hospital in miryalaguda , they referred him to hospital 2 (our management) where tracheostomy was done ;

Since then he had multiple episodes of edema for which he took hydrocortisone and avil at home and if there was any episode of breathlessness and difficulty in swallowing he came to hospital.

** Tracheostomy was done twice in the same hospital in 2007 & 2016. ( at both instances he developed edema of uvula )

— He also had multiple episodes of edema of limbs and face which resolved on its own at home

— Last episode of edema of face in December 2020

Patient usually develops swellings when exposed to smoke/dust/perfume/alcohol smell/while cooking , when he eats certain foods (mutton,fish,brinjal,sorrel leaves).

Swellings usually appear 5 to 10 hours of exposure to triggers

Patient also gets the edema when he is stressed if they're any fights or loud voices.

Episodes are more in winters than in summers.

Patient is taking all precautions so he won't have an episode again but he is scared that he will have another episode as he has many triggers and his sleep is disturbed from an year.

No history of decreased frequency of urination , peri orbital edema , burning micturition.

PAST HISTORY:

Not a known case of DM/HTN/TB/BA.

No history of any other surgeries

FAMILY HISTORY:

No similar family history

ON EXAMINATION:

Patient is c/c/c

No signs of pallor or cyanosis or clubbing or icterus or koilonychia or lymphadenopathy.

Edema of the limbs : absent

Edema of uvula & larynx : present