Complete Case Presentation Script (A–Z) Good morning doctor. I would like to present my case. My patient is Mr. X, a 56-year-old gentleman who presented to the clinic for asthma follow-up with occasional wheezing and shortness of breath for 2 days. History of Present Illness Patient is a known case of bronchial asthma, Type 2 Diabetes Mellitus, hypertension and dyslipidemia for the past 10 years and is on regular follow-up at Kementerian Kesihatan Malaysia Klinik Kesihatan every 3 months. He came today for asthma follow-up and complained of occasional wheezing and intermittent shortness of breath for the past 2 days. The shortness of breath was gradual in onset, intermittent in nature and associated with wheezing. Symptoms worsen during night time and with dust exposure. There was no fever, cough, sputum production, hemoptysis or chest pain. No symptoms suggestive of upper respiratory tract infection. Patient uses inhaler regularly and claimed compliance to medications. There was no history of ICU admission or intubation due to asthma. There were also no symptoms suggestive of diabetic complications such as polyuria, polydipsia, blurring of vision, numbness of feet or non-healing ulcers. Patient claimed blood pressure and blood sugar were controlled during previous follow-up. --- Systemic Enquiry General System No fever, loss of weight or loss of appetite Respiratory System Occasional wheezing and shortness of breath present No cough, sputum or hemoptysis Cardiovascular System No chest pain, palpitations, orthopnea or PND Endocrine System No polyuria, polydipsia or polyphagia Neurological System No headache, dizziness or weakness of limbs Peripheral Vascular / Diabetic Complication Screening No blurring of vision No numbness of feet No non-healing ulcers Genitourinary System No dysuria or reduced urine output --- Past Medical and Surgical History Bronchial asthma for 10 years Hypertension for 10 years Diabetes Mellitus for 10 years Dyslipidemia for 10 years No previous surgery No history of tuberculosis --- Drug History Currently patient is taking: Metformin Amlodipine Atorvastatin Salbutamol inhaler Patient claimed compliance to medications. No known drug allergy. --- Family History No family history of asthma or other chronic respiratory disease. No family history of premature cardiovascular disease. --- Social History Patient is independent in daily activities. No smoking or alcohol history. Avoidance of dust exposure was advised. --- General Physical Examination Patient was conscious, alert and comfortable at rest. Patient was not tachypneic and not in respiratory distress. No cyanosis, pallor, jaundice or clubbing. No pedal edema. Hydration status was adequate. Vital Signs Blood pressure: 130/80 mmHg Pulse rate: 84 beats per minute, regular Respiratory rate: 20 breaths per minute Temperature: afebrile Oxygen saturation: 98% on room air --- Respiratory Examination On inspection, chest was symmetrical with no deformity. Trachea was centrally located. Chest expansion was equal bilaterally. On auscultation, mild bilateral wheezing was heard. No crepitations were noted. --- Cardiovascular Examination Pulse was regular with good volume. Heart sounds S1 and S2 were normal. No murmur was heard. --- Neurological Examination Patient was conscious and oriented. No focal neurological deficit. --- Diabetic Foot Examination No ulcer or deformity noted. Peripheral pulses were palpable. Sensation was intact. --- Summary This is a 56-year-old gentleman who is a known case of bronchial asthma, Type 2 Diabetes Mellitus, hypertension and dyslipidemia for the past 10 years on regular follow-up at primary care clinic, who presented with intermittent wheezing and shortness of breath for 2 days, worsened by dust exposure and at night. There were no symptoms suggestive of infection or acute severe asthma. Examination revealed mild bilateral wheezing without respiratory distress. --- Provisional / Definitive Diagnosis 1. Partially controlled bronchial asthma on follow-up 2. Type 2 Diabetes Mellitus under follow-up 3. Hypertension under follow-up 4. Dyslipidemia under follow-up --- Investigations Investigations done and planned include: PEFR Pulse oximetry DTX/HbA1c Lipid profile Renal function test Urine microalbumin ECG Blood pressure monitoring --- Management Plan Continue asthma inhalers Continue antihypertensive medications Continue diabetic medications Continue statin therapy Advise avoidance of asthma triggers Lifestyle modification including diet and exercise Education on inhaler technique and medication compliance Regular follow-up at Klinik Kesihatan every 3 to 6 months give me a proper provisional and definitve diagnosis for this case..im not happy with the answer i have uploaded