65M came with c/o hempotysis

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome

Thanks and acknowledged from Dr K.G.Prasuna reddy case report

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 come up with a diagnosis and treatment plan. 



THESIS CASE PRESENTATION: :

THIS IS A CASE OF A 67 YR OLD MALE, RESIDENT OF NALGONDA, Farmer by occupation,CAME TO THE CASUALTY WITH CHIEF COMPLAINTS IF HEMOPTYSIS FROM 3 MONTHS.

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YRS BACK WHEN HE STARTED TO DEVELOPTINGLING SENSATION IN B/L UL AND LL AND GIDDINESS ON WAKING UP EARLY IN THE MORNING. And diagnosed with type 2 diabetes mellitus. And started him on OHA's.
HE THEN DEVELOPED DIMINISION OF VISION IN THE LEFT EYE SINCE 5 YRS.
SINCE 8 MONTHS, HE HAS BEEN HAVING FEVER ASSOCIATED WITH CHILLS, CONTINUOUS TYPE, LOW GRADE, ASSOCIATED WITH BURNING MICTURATION, NOT ASSOCIATED WITH ANY DIURNAL VARIATION .
6 MONTHS AGO, HE BEGAN TO DEVELOP COUGH WITHOUT SPUTUM BUT GRADUALLY BECAME PRODUCTIVE, WHERE SPUTUM WAS MUCOID, WHITISH YELLOW. THEN, IT PROGRESSED TO BLOODY SPUTUM SINCE 3 MONTHS . 
SOMETIMES COUGH IS FOLLOWED BY VOMITING EPISODES WITH VARIABLE CONTENTS.
H/O WT LOSS OF 20KG IN 6 MONTHS 
ASSOCIATED WITH CONSTIPATION. ( PASSES STOOLS ONCE IN 3 DAYS )
SINCE 3 MONTHS, HE HAS BEEN HAVING EPISODES OF VOMITINGS, 1 EPISODE AFTER FOOD EVERYDAY WITH FOOD AS CONTENT.
HE ALSO COMPLAINS OF DRY MOUTH, POLYPHAGIA, POLYDYPSIA, POLYURIA, NOCTURIA.
NO COMPLAINTS OF LOSS OF APPETITE.

HE IS A K/C/O DM TYPE 2 SINCE 15 YRS AND IS ON TAB GLYPIZIDE+METFORMIN
AND HTN AND IS ON TAB ATEN-AT 25/10
NOT K/C/O EPILEPSY, ASTHMA, TB,CVA,CAD

PERSONAL HISTORY:
SLEEP: ADEQUATE
APPETITE: NORMAL
DIET: MIXED
BOWEL: IRREGULAR
BLADDER: BURNING MICTURATION 
ADDICTIONS: CONSUMED ALCOHOL 20 YRS AGO, NOW STOPPED

NO SIGNIFICANT FAMILY HISTORY 

GENERAL EXAMINATION:
DONE AFTER OBTAINING CONSENT, IN THE PRESENCE OF ATTENDER, WITH ADEQUATE EXPOSURE
HE IS CONSCIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME PLACE, MODERATELY BUILT AND NOURISHED
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 

VITALS AT ADMISSION:
TEMP: 98
PR: 88BPM
RR: 20CPM
BP: 110/90MMHG
SPO2: 98% AT RA
GRBS: 410MG/DL

SYSTEMIC EXAMINATION:
CVS: S1, S2 HEARD
PA: SOFT, NON TENDER, BS PRESENT
CNS: NO FOCAL ABNORMALITY 

RS:
INSPECTION: 
RT SIDE INCREASED BREATH SOUNDS
TRACHEA TO THE RIGHT
PALPATION:
DECREASED BREATH MOVEMENTS ON THE RIGHT
PERCUSSION:
RIGHT MAMMARY DULL, REST RESONANT
AUSCULTATION:
VESICULAR BREATH SOUNDS HEARD, NO CREPTS, NO RONCHI

INVESTIGATIONS:
on 9/12/22



TREATMENT:
9/12/22
IVF NS
INJ NEOMOL 1G IV SOS
TAB ATEN AT 25/5
SYP AMBROXOL 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS


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