A 52 year old man suffering with chest pain since 3 year

Pt. Botanical I.d. -blumea486balsamifera02 AJ

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016after collecting informed patient consent (form downloadable here)

Pt. Voice history-

Age 52/m

Occupation- work at mandir

Add.

Vital sign- b.p.- 120/80,

R.r.-21/min.

Pluse-76/min,

Tem.- 98.4°f

C/o- breathlessness during walking, chest pain rt. Side, decrease vision, cough and cold, constipation,

Past h/o- no any surgery 

Personal h/o- nutrition poor,

Tobacco and supari chewing continue to last 18 year..

Environment- cloudy area,

In home pt. Live with some pat animal like cow and buffalo and near dog..

Family h/o- no any one ill in pt. Home all are good and doing work, paternal- mother and father's was died and one elder brother also.

Patients image

Present Dr.notes

Chest-Xray

Objective examination

Hair normal

Neck posture normal

Facial expression normal

And Pain areradiat left arm

Aggravating factor- any heavy work and outstretching hand posture

Relieving factor- pain killer medicine - aspirin.

 Shoulder rang are normal

Chest expansion- 2c.m. 

On palpation

Temperature- 98.4°f

Tenderness- no any

Oedema- no

Contracture-no

Abdominal- no any tenderness 

Neurological test -

Dermatomes-

Reflexes-

Myotomes-all are good no other complaints

Analysis

According to Pt. Complaints - pain present in lower left chest area (7-9 rib )

And pt. Chewing tobacco, and supari,

And breath shortness during any work at winter time more then summer

Its more sign. Of copd ...

"COPD....?

And according to xray report - 1 nodules are present in left chest side.

Planning-

 Medication

Nebulization with asthelin

And continue current medication.