A 65-year-old
E LOG MEDICINE CASE
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Name: Kadadasu Srijani
Roll no : 54
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.
A 65 year old male farmer by occupation came to general medicine OPD with
CHIEF COMPLAINTS :-
Chest pain radiating to shoulders since 6 months
Back pain since 5 months
Ribs pain, Chest tenderness and Cough since 3 months
Cough with blood since 1 month
Fever with sweating, shortness of breath, dizziness and sweating since 1 month
HISTORY OF PRESENT ILLNESS :-
Patient was apparently asymptomatic 6 months back. Then patient developed chest pain, chest tenderness and ribs pain 6 months back followed by back pain since 5 months and cough since 3 months. Patient gave complaints of Hemoptysis, fever with sweating, shortness of breath and dizziness since 1 month. He was admitted on 9-12-2022. History of weight loss of 20kg was seen. He has no history of trauma or injury.
HISTORY OF PAST ILLNESS :-
History of Diabetes Mellitus Type II since 15 years.
History of hypertension since 15 years.
No history of epilepsy, CAD, Bronchial asthma.
FAMILY HISTORY :-
Known history of DM, HTN and asthma for his parents.
PERSONAL HISTORY:-
Mixed diet
Normal appetite
Adequate sleep
Burning micturition
Bowel-irregular constipation
He had a history of smoking and alcohol consumption 20yrs back.
No known allergies
DRUG HISTORY:-
He is taking medications for DM and HTN:
Oral medication: Metformin + Glimiperide for DM II
Amliodipine for HTN
PHYSICAL EXAMINATION:-
GENERAL EXAMINATION:-
Conscious, coherent and cooperative
Well oriented to time place and person
Examined in sitting position
Poorly built
Malnourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
No pedal edema
VITALS:-
Temperature (febriline): 101 degree Fahrenheit
Pulse Rate: 78 beats per minute
Respiratory rate: 20 times per minute
BP: 110/85
SYSTEMIC EXAMINATION:-
CVS:
S1, S2 sounds heard
No audible murmurs
No thrills
Abdomen:
Shape of abdomen: Scaphoid
No visible scars
Movement of abdomen moves equally with respiration
Respiratory system:
Inspection:
Bilaterally symmetrical
No visible scars
Palpation:
Position of trachea central
Apex beat felt
Explanation of chest: symmetrical
Vocal fermitis: equal on both sides
Percussion:
Auscultation:
Breath sounds
Vocal resonance
No added sounds
Investigations:
PROVISONAL DIAGNOSIS:-
Pulmonary Koch’s
TREATMENT :-
TAB ATT 3 TABLETS ACC TO WT
TAB INH 225MG PO OD
TAB RIFAMPICIN 450 MG PO OD
TAB PYRAZINAMIDE 1200 MG PO OD
TAB ETHAMBUTOL 825 MG PO OD
2 TAB BENADON 40MG PO OD
4 INJ HAI S/C TID 14-14-12, PH S/C BD 10-X-8 ACC TO GRBS
5 INJ VIT K 1 AMP IN 100ML NS
6 INJ TRANEXA 500ML IV SOS
7 INJ AMLONG 5MG PO OD
Patient got discharged on 19/12/2022 with medications.
