This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
This E blog also reflects my patient-centered online learning portfolio and your valuable input in 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
A 60 yr old female resident of nalgonda maid by occupation came to our opd with following chief complaints.
Chief complaints:-
Cough with sputum since 30days
Blood sputum nearly 3 times
Fever with chills and rigor since 20 days
Dysnea since 15 days
HOPI:
Patient was apparently asymptomatic 30 days back she then developed productive cough with was insidious in onset ,also complains of blood filled sputum nearly 3 episodes( each episode about 10ml vol. MILD HEMOPTYSIS) with no aggrevating or relieving factors.
Complaints of fever which was continous associated with chills,rigor and night sweats.
Two episodes of non projectile, non bilious vomitings containing food particles but not blood products.
Dyspnea grade 2 not associated with wheeze ,othopnea,PND,
Loss of weight since one month with complaints of generalised weakness,chest tightness,
PAST HISTORY:
No h/o similar complaints in the past
No h/o of tuberculosis
H/o cardiac surgery 6 yrs back(CABG),medication used are furosemide,aspirin and oral acitrom(vit k epoxide reductase inhibitor)
Diabetic since 8 yrs,medication used are metformin,glimiperide,voglibose( alpha glucosidase inhibitor)
Not a k/c/o HTN,ASTHMA,THYROID ABNORMALITIES,EPILEPSY.
H/o of 4 blood transfusions during cardiacs surgery.
PERSONAL HISTORY:
Sleep adequate
Appetite normal
Bowel and bladder regular
No h/o of allergies
Occasional alcohol intake 60ml whiskey once a week since 10 days
Regular smoker ,smokes 5 chutta per day.
Family history:
Both parents are diabetic
Father had a history of heart attack.
No family history of HTN ASTHMA COPD.
MENSTRUAL HISTORY :
AGE OF MENARCHE 13 yrs
Age of menopause 40 yrs.
OBSTETRIC HISTORY:
Married since 40 yrs.
GENERAL PHYSICAL EXAMINATION:
No pallor cyanosis icterus clubbing lympadenopathy edema
Temp 100.2 F
PR 94bpm
Bp 100/70
Spo2 99@ra
GRBS 135 mg/ dl.
SYSTEMIC EXAMINATION:
CVS S1 S2 heard,no murmurs.
CNS NO FND.
ABDOMEN NO ORGANOMEGALY.
RESPIRATORY EXAMINATION:
Upper respiratory examination:
no dns,no polys,no post nasal drip,no pharyngeal wall inflamation.
Oral cavity dental caries present, 2 teeth are lost.
Inspection:
Shape of chest elliptical
symmetrical and normal chest movements
Trachea appears to be central ( trails sign negative)
No structural abnormalities seen
No scars,sinuses seen.
Palpation:
Transverse diameter 23cm
AP diameter 16cm
Chest circumference 63 cm
After inspiration circumference 68cm
Trachea central - 3 finger test
Symmetrical chest movements with respiration
Tactile vocal fremitus- slightly reduced in the left supraclavicular and left supra scapular regions
Apical pulse felt 1 inch medial to mid clavicular line in right fifth ics.
No tenderness over the chest region.
Percussion:
Impaired percussion note observed in left supraclavicular and left supraspinatous regions.
No tenderness on percussion
Liver dullness at 5th ics
Cardiac dullness within normal limits
Auscultation: normal breath sounds heard.
PROVISIONAL DIAGNOSIS:
Left upper lobe cavity with TB and diabetes.
Investigations:
Chest x ray:
Diagnosis: left upper lobe cavitation due to TB infection secondary to daibetes.
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