50 yr old male with fever and cough with sputum.

 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on 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 come up with diagnosis and treatment plan.

Patient came with chief complaint of cough since 

7 Days, Fever since 7 days, with difficulty in breathing since 7 days

History of presenting illness:

Fever since 7-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

NO H/O similar complaints in the past 

No past H/O TB, loss of appetite, loss of weight

K/C/O: Dm+ since 2years 

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

- H/o -electrocution 
 4-years back - Burns both hands

PERSONAL HISTORY

Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day. 

Patient attendant said that their neighbour has TB ( who is son in law of him )

And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day

Patient started to have fever since 10 days at night time with burning sensation all over the body

Patient started to have unbearable pain at lower back  during cough .and always needed help from attendants to hold his back during coughing.

PAST HISTORY

K/c/o DM  since 2 years was diagnosed during his RTA treatment and is on regular Glimiperide 1mg &Metformin 500mg medication since then.

He has no history of  hypertension, diabetes ,asthma, epilepsy, tuberculosis.

GENERAL EXAMINATION 

Patient is conscious, cooperative ,coherent and oriented with time , place , date.
Slightly pallor, 
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:
Bp-80/40 mm Hg
Pr-102 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH

 

Sputum sample:

       

Burns in both hands: 

Slight discoloration on lower back:

Surgical implant (L) Leg scar:

SYSTEMIC EXAMINATION

CVS:S1 S2 heard , No murmurs 

CNS:

No focal neurological deficit

RS:

Breath movements -abdominal thoracic

In infra scapular area of left lung

Inspection: chest shape normal, 

Dysponea - present

Palpation: trachea -central

Auscultation: basal crepitations are heard

INVESTIGATIONS

 06.05.2023

  07.06.2023

HRCT - Findings 

                            06.06.2023

PROVISIONAL DIAGNOSIS

Fungal Ball Aspergilloma(?)

Cavitating pneumonia(?) TB (?) Uncontrolled Sugars (resolving)

TREATMENT

IV Fluids@ 75ml /hr

Inj.Neomol 1gm IV/SOS (if temp more than 101 F)

Tab.Dolo 650mg PO/TID

Syp.Grillinctus dx 2tsp PO/TID

Inj HAI S/C TID ( acc to GRBS )

Inj Augmentin 1.2gm Iv/ BID