a 50yr old farmer came with cough with blood
Hi, I am shaik ayesha 5th Sem Medical Student.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 patient's clinical problems with collective current best evidence based inputs. This E log book 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 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
PAST HISTORY
Known case of DM type 2 since 1yr and is on medication
He had accident 1yr ago and underwent hip surgery where he was diagnosed with DM
He had fever
No vomitings , constipation, diarrhea
No HTN,CAD,asthma ,TB , epilepsy,thyroid disorders ,blood transfusions
Hip surgery 1yr ago
FAMILY HISTORY
no significant history
Healthy sibling history
PERSONAL HISTORY
married
Farmer by occupation
Normal 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
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
pulse 88bpm
BP
Temp
Respiration 20 /min
SYSTEMIC EXAMINATION
respiratory system
Inspection
Chest symmetrical
Trachea Centrally placed
Palpation
Percussion
Ascultation
Other systems
CVS
ABDOMEN
no hepatosplenomegaly,ascites
CNS
Investigations
6/6/23
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