A 70 year old male with dysphagia

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan .

 70 yr old male came to opd with chief complaints of dysphagia since 10 days

HOPI : Patient was apparently asymptomatic 10 days back then he  developed difficulty in swallowing which is insidious in onset ,gradually progressive ,more for solids than liquids associated with nasal regurgitation of food, he had fever 10 days back  which is intermittent in nature ,associated with chills and rigor and it  relived on taking medication.

no H/o throat pain,difficulty in breathing,no H/o nasal obstruction,nasal discharge,bleeding from nose

NO H/O decreased hearing,ear pain,discharge

past history: no h/o diabetes  mellitus hypertension ,asthma ,epilepsy,CAD

TB .

NO H/O blood transfusion and surgeries in the past.

he gives a history of clavicle fracture 30 years back.

PERSONAL HISTORY: DIET: mixed

APPETITE: Normal

SLEEP : Adequate

BOWEL AND BLADDER: REGULAR

Addictions : alcohol ( daily 50 ml)

 since 40 years.

smoking (3 to 4 beedis)

Family history: no significant family history.

General physical examination: 

patient is conscious,coherent,cooperative,well oriented to time ,place,and person.He is thin built and poorly nourished.

pallor: present

icterus:absent

clubbing:absent

cyanosis:absent

lymphadenopathy: absent

edema: absent

vitals at the time of admission:

Temperature: 98.6 °c

blood pressure:110/70 mm hg

respiratory rate:14 cpm

pulse rate:86

GRBS:106 mg %

SPO2 at room air:98%

systemic examination:

cardiovascular system:

s1 and s2 sounds heard ,no murmurs

no thrills.

respiratory system: position of the trachea:  central, Bilateral air entry present ,normal vesicular breath sounds ,no adventitious sounds.no dyspnea and wheeze.

CNS: no focal neurological deficits.

speech normal, no signs of meningeal irritation.

cranial nerves ,motor system ,sensory system - normal

P/A Examination:

soft ,non tender,no organomegaly.

shape of abdomen: scaphoid 

spleen and liver not palpable

no scars ,sinuses,

no signs of fluid accumulation

endoscopy report:  bile reflex gastritis

provisional diagnosis: dysphagia  due to bile reflex gastritis