35 year old male with non productive cough since 6 months

 Hi, I am D.Vasista Pranav  5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This e-log also reflects my patient centered online learning portfolio  

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.

A 35-year-old male presented with the chief complaints of episodic dry cough and noisy breathing since 7 months. 

History of Presenting Illness:

The patient was apparently asymptomatic 7 months ago when he first noticed a dry hacking cough and noisy breathing that was insidious in onset and gradually progressed to his current frequency. 

He first went to a local physician who prescribed him a 1 week course of antibiotics. On noting no improvement, he went to a physician again who prescribed him a second week long course of antibiotics. This is his third visit for his ailment. The patient has had no previous imaging done. 

The cough is aggravated by several factors: 

1. Cold weather/ AC rooms/ cold breeze hitting his face
2. Exertion (when asked about the type of activity, he says riding his bike in the summer months or brisk walking to work makes it worse) 
3. Lying down/sleeping: he complains of severe cough and noisy breathing when he lies down to go to bed, to the extent where he cannot sleep and needs to sit upright or take a walk. He says taking a walk decreases his cough in such instances. 

24/7/23: The patient couldn't sleep all night because of his cough. 

Prolonged coughing leads to chest pain and shortness of breath in his case.

The patient complains of increased fatigue and weakness in the past 6-7 months. He says he has not had any weight changes as all his clothes fit him the same. He has had no changes in appetite. 

History of past illness:

K/C/O Hypertension since 2 years. 

Complains of occasional dry eyes at the end of the day. 

Not a known case of DM, Asthma, TB, Epilepsy, CAD, CVD

Medication History:

He was prescribed this antihypertensive 2 years ago and has been taking it ever since.He was diabetic.He  was a  previous case of covid 19 infection in 2020.

The patient's wife has had chest pain for the past 6 months and complains of increasing abdominal distension since her C- section in 2021. Her chest pain worsens at night.

General physical Exam:

On admission:

Vitals: 

Afebrile (98.6)

BP: 110/70mmHg

HR: 80bpm

RR: 16cpm

SpO2: 98% on RA

GRBS: 107mg/dL

Patient is conscious, coherent and cooperative, well oriented to time, place and person. 

No signs of pallor, cyanosis, icterus, lymphadenopathy, clubbing or pedal edema.

JVP normal

Systemic exam:

Cardiovascular System: S1, S2 heard, no murmurs.

Respiratory System: BAE+, VBS, stertor+ at the time of examination, 

Per Abdomen: Soft and non tender, no organomegaly. 

CNS: C/C/C, AOx3, no focal neurological defects, CN function intact.

Investigations: 

Patient has not consented to any investigations as of now.

Provisional diagnosis: Episodic paroxysmal cough in a known case of hypertension? Asthma? 

Treatment: 

TAB CETIRIZINE 10mg PO OD 

TAB PANTOPRAZOLE 40mg PO OD before breakfast 

TAB ULTRACET PO 1/2 QID