A 50 year old male patient came to opd with complaints of cough
7/06/23
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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 a diagnosis and treatment plan.
CHIEF COMPLAINTS
A 50yr male patient farmer by occupation came with cheif complaints of cough since 4 days and fever since 3 days
HOPI
The patient was apparently asymptomatic 4 days ago
Patient had productive dry cough with bloody sputum with episodes which last for 30mins which was scanty in quantity
He had body pains and stomach pain SOB grade 2 while coughing and had fever since 3 days
7/6/23 morning he had 3 episodes of bloody sputum scanty in amount and on 6/6/23 he had 4 episodes
He had hoarseness since 4 days
And slight changes in weight loss
. Patient attendant said that their neighbour has TB ( who is son in law of him )
And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day
Patient started to have fever since 10 days at night time with burning sensation all over the body
Patient started to have unbearable pain at lower back during cough .and always needed help from attendants to hold his back during coughing.
PAST HISTORY
Known case of DM type 2 since 1yr and is on medication
3 years ago he had electric shock
He had accident 1yr ago and underwent hip surgery where he was diagnosed with DM
He had fever spikes in evenings
No vomitings , constipation, diarrhea
No HTN,CAD,asthma ,TB , epilepsy,thyroid disorders
No blood transfusions
Surgeries:Left hip surgery one year ago due to RTA
FAMILY HISTORY
no significant history
Healthy sibling history
PERSONAL HISTORY
married
Farmer by occupation
Slight decrease in appetite
Mixed diet
Since 4 days patient is unable to sleep due to cough and remains awake
Normal micturation
Normal bowel movement
No known allergies
Addictions : used to smoke tobbacco (sutta) since he was 20yrs of age once a day and stopped recently after cough.Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day
PHYSICAL EXAMINATION
GENERAL EXAMINATION
conscious coherent cooperative
Lean built
Moderately nourished
Pallor mild
No icterus
No cyanosis
No clubbing of fingers
No pedal edema
No lymphadenopathy
VITAL SIGNS
Bp-80/40 mm Hg
Pr-102 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH
SYSTEMIC EXAMINATION
RS:
Breath movements -abdominal thoracic
In infra scapular area of left lung
Inspection: chest shape normal,
Dysponea - present
Palpation: trachea -central
Auscultation: basal crepitations are heard
CVS:S1 S2 heard , No murmurs
CNS:
No focal neurological deficit
ABDOMEN
no hepatosplenomegaly,ascites
Investigations
On 7/6/23
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