A 65 yr old male patient with fever, chills and cough with haemoptosis

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed 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.

CHEIF COMPLAINT:
A 65 year old male patient ,worker by occupation came to the causality with the cheif complaint of:

Fever and chills since 8 months
Chest pain radiating to shoulders since 6 months
Cough since 6 months
Hemoptosis since 3 months

HISTORY OF PRESENT ILLNESS:
Dry mouth, polyuria, polydipsia, nocturia, decrease in vision since 5 years.
Fever is continuous and no diurnal variation, low grade and prescence of chills since 8 months.
Cough is productive, sputum is mucoid consistency and whiteish yellow colour sometimes blood tinged since 6 months , dizziness, chest pain on coughing and abdominal pain since 6 months.
Hemoptosis with bright red clots  since 3 months. Burning micturation, constipation , passing the stools once in 3 days, vomiting one episode after intake of food every time since 3 months.

Daily routine: wakes up by 6 o' clock and does his daily chores and has tiffin and went to work and return home then had dinner and sleeps by 9 pm

HISTORY OF PAST ILLNESS: 
Known complaint of diabetes mellitus since 20 years (on medication, glimperide and metformin)
Known complaint of hypertension since 20 years ( on medication,atenolol)
No known complaint of asthma , epilepsy,CAD.
PERSONAL HISTORY:
Built: moderate 
Appatite: lost
Sleep : inadequate
Bowel movement: irregular( constipation) 
Micturation: burning micturation
No known allergy to drugs
Habits/addictions: 
He use to consume alcohol 20 years back of 1 bottle beer or a quater bottle of alcohol daily and also consumption of toddy.
He had habit of smoking 20 years back 4 cigars and 4 packs of bedi daily
Now completely stoped
FAMILY HISTORY:
NO known relevant family history.
PHYSICAL EXAMINATION: I have taken the consent of the patient. Patient is conscious coherent  coperative and well oriented to place, person and time.
Weight: 45 kgs ( decrease in weight since 6 months)
Pallor: no
Icterus: no
Cyanosis: no
Lymphadenopathy; no
Clubbing of fingers: no
Malnutrition: poorly nourished
Edema: no
VITALS: Temperature: afebrile.
               Blood pressure: 150/80mm hg
               Respiratory rate: 20 / min
                Pulse rate: 88
SYSTEMIC EXAMINATION:
Respiratory system: 
Dyspnea: present
Lower respiratory tract
Inspection:
Chest: asymmetrical
Trachea right side deviation
No nodule and dilated veins are seen
Palpation:
Decreased breath movements
Trachea right deviation
Right scapula show prominence
Local fremitus is high in right side.
Chest expansion 31 meters on expiration and 32 meters on inspiration.
AP measurment 7 meters and transverse measurment : 15 meters
Percussion:
On percussion supraclavicular and axillary have resonating sound on both left and right lungs. left mammory shows resonate.right mammory area shoes dull note.
Ascultation: vesicular breath sounds are heard.
                                 Right.                Left
Supraclavicular.         NVBS             Normal
ABDOMINAL EXAMINATION:
Inspection:
shape : scaphoid.
Umbilicus: central placed and inverted
Flank : right flank is full , left flank is free.
No dilated veins
No scars on the abdomen
Palpation:
Liver and spleen are not palpable
No tenderness
INVESTIGATIONS
PROVISIONAL DIAGNOSIS:
Uncontrollable diabetes.
Pulmonary tuberculosis
Community acquired pneumonia.



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