49 YEAR OLD MALE WITH COUGH SINCE 20 DAYS
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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 diagnosis and treatment plan.
A 49 year old male resident of Gujji ( Yadadri district ) daily wage worker by occupation presented with chief complaints of
- Cough since 20 days
- Decreased appetite since 20 days
Patient was apparently asymptomatic 20 days ago then he developed productive cough which was mucoid in nature for which he went to local hospital but not subsided with treatment and presented to us with cough which is gradually progressive in nature, mucopurulent, scanty, brownish, foul smelling, non blood stained, more in the night. Hialatosis is present.
He also complains of decreased appetite since 20 days and complains of weight loss ( 59 to 40 kgs in a span of 6 months ).
No history of fever, chest pain, shortness of breath, sweating, palpitations.
Past history:
No history of similar complaints in the past.
Not a known case of Diabetes, Hypertension, Asthma, Thyroid, Tuberculosis, Epilepsy
Treatment history:
Not significant
Family history:
Not significant
Personal history:
Diet is mixed
Appetite is decreased since 20 days
Bowel and bladder movements are regular
Sleep is decreased due to cough during night time
History of occasional alcohol consumption since 20 years and stopped 2 months ago.
History of chewing thambaku since 25 years and stopped 1 month ago.
No allergies to any food or drugs.
GENERAL EXAMINATION :
patient is conscious,coherent and cooperative ,well oriented to time, place and person.
thin built and poorly nourished
No pallor, icterus, cyanosis, clubbing, lymphadenopathy,pedal edema.
VITALS :
BP -110/70 mmHg
TEMP- afebrile
RR-20 cpm
PR- 86bpm
spO2- 98% at room air
GRBS -424mg%
SYSTEMIC EXAMINATION :
Respiratory system:
INSPECTION:
Upper Respiratory tract:
Nose- no polyps, dns
oral cavity- dental stains are present
Post pharyngeal wall- normal
Lower respiratory tract:
Shape of chest : bilateral symmetrical,elliptical
trachea: central
supraclavicular hollowness absent
chest expansions equal on both sides
no crowding of ribs,no drooping of shoulders
no wasting of muscles
no usage of accessory muscles of respiration
apical impulse not seen
no scars,sinuses, engorged veins, visible pulsations
Hypopigmented patches are seen all over the chest
no kyphosis ,scoliosis
PALPATION :
all inspectory findings are confirmed
no local rise of temperature
no tenderness
trachea central in position
apex beat left 5th ICS,medial to mid clavicular line
Tactile Vocal fremitus increased at right interscapular region
Diameters
Anterioposterior: 28 cms
Transverse: 24 cms
Chest circumference: 84 cms
PERCUSSION:
Resonant and equal in all areas.
Right left
Supraclavicular- (R) (R)
Infraclavicular- (R) (R)
Mammary- (R)( R)
Axillary- (R) (R)
Infra axillary- (R ) ( R)
Suprascapular- (R) (R)
Interscapular- (R) (R)
Infrascapular- ( R ) (R)
AUSCULTATION:
BAE+
Normal vesicular breath sounds heard
No added sounds
Vocal resonance increased in right interscapular area.
CVS-
Auscultation: S1S2 heard, no murmurs
CNS : The patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal
. Reflexes are normal .
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
No cerebellar signs .
No meningeal signs.
PA- soft, non tender, no organomegaly, no distension, bowel sounds heard.
INVESTIGATIONS:
2/1/2023
Chest X- ray
Plain X ray PA view of chest showing a cavitatory lesion in the right upper lobe.
4/1/2023
5/1/2023
Provisional diagnosis:
Treatment:
- Inj. Piptaz 4.5 mg IV TID
- Inj. Metrogyl 500 mg TID
- Inj. PAN 40 mg BBF
- Syp. Aptivate 10ml/BD
- NS IV 500 ml@ 100ml/hour
- Inj. HAI according to GRBS
- Inj. Thiamine 100 mg/ IV/BD
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