A 40 year old male presented with cough with blood since 15/12/2022
December 21, 2022
General medicine case discussion
E LOG MEDICINE CASE
21/12/2022
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Name: K. Supraja
Roll no : 60
2020 Batch
I''ve 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 comeup with Diagnosis and Treatment plan.
Case presentation:
A 40 year old male came to general medicine OPD with chief complaints of:
Cough with blood since 15/12/2022
Chest tightness on taking breath and breathlessness since 15/12/2022
Generalised swelling of body since 15/12/2022
History of present illness:
Patient was apparently asymptomatic 7 days back. Then patient developed
*hemoptysis - cough with blood, mucusopurulent, no foul smell, initially started as small amount increased to handfull amount within 3 days.
*Also developed generalised swelling of body -pedal edema, facial fluffiness since 15/12/2022.
Patient gave complaints of breathlessness, dyspnoea on lying down, which relieved on sitting.
He was admitted on 18-12-2022..
Past History:
No history of similar complaints in the past.
No history of epilepsy,HTN, DM, Bronchial asthma.
Surgical history: He has a history of total thyroidectomy due to papillary CA of thyroid 5 years back. Radiation exposure 4 years ago.
On medication tab. Thyroxine 100mg OD
Family History:
No Known history of DM, HTN ,TB ,epilepsy and bronchial asthma for his parents.
Personal History:
Mixed diet
Normal appetite
Inadequate sleep
No Burning micturition
Bowel- regular
No known allergies
No addictions
Drug History:
Tab thyroxine 100mg OD.
Due to the intake of outdated medicines of thyroid, patient complained of blood stained cough with sputum.
Physical Examination:
General Examination:
Conscious, coherent and cooperative
Well oriented to time place and person
Examined in sitting position
Moderately built
Moderately nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
pedal edema - pitting type on 18 /12/2022
Decreased swelling of body and pedal edema by 21/12/2022
Vitals:
Temperature (afebrile): 98.6degree Fahrenheit
Pulse Rate: 119 beats per minute
Respiratory rate: 30 times per minute
BP: 110/70
SpO2 : 87% at room temperature
GRBS- 120 mg / dl
Systemic Examination:
Respiratory system:
INSPECTION
Shape of chest elliptical
Bilaterally symmetrical
No visible scars
Position of trachea central
Explanation of chest: symmetrical
Accessory muscles of respiration are not in use
No drooping of shoulders
No crowding of ribs
No wasting of muscles
Apical impulse not seen
PALPATION
no local rise in temperature
No tenderness
All inspectory findings are confirmed
Chest movemente equal on both sides
PERCUSSION
direct - resonant
Indirect- resonant
AUSCULTATION
Vocal fermitis: equal on both sides
Breath sounds
Vocal resonance
No added sounds
Other systems:
CNS: no facial assymetry, all reflexed are normal
GIT: no hepatosplenomegaly, no ascites
Investigations:
Hemogram,Chest x ray.
Provisional Diagnosis:
Under evaluation
