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

History of present illness:

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- 

Palpation:

• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 

• JVP was normal 

• No parasternal heave

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:

Right upper lobe cavitation ( Aspergilloma?) with denovo DM type 2.

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