57/M with hemoptysis



 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .



I’ve 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


57/M patient came to casualty on 10-11-22 at 10:30pm c/o haemoptysis  and C/o bloody discharge from nose since 4hrs and cough on and off since 2 days associated with blood 
C/o Cough associated with blood and Pain abdomen 

       
Past history: 
K/c/o HTN since 7 years and on medication Amlodepine 5mg 
Personal history: 
Diet: mixed 
Appetite: normal 
Sleep: adequate 
Bowel and bladder habits: regular 
Addictions: none 
Allergies: none 

Family history: insignificant 

General examination: 
Pt is conscious coherent and cooperative 
Well oriented to time, place and person 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema 
Vitals: 
Temp: 98.6F 
BP: 120/80mm Hg 
PR: 82bpm 
Spo2: 96% 
GRBS: 115mg/dl 

Systemic examination: 

CVS: s1, s2 heard 
RS: BAE+ NVBS 
P/A: soft ,non tender ,bowel sounds heard 
CNS: NFND 

Investigations: 


Hemogram: 
On 11-11-22: 


    


On 12-11-22

On 13-11-22



RBS: 

     


LFT: 

     
      

RFT: 

       


BT and CT: 

       

PT and INR : 

       

APTT:

          


Serology: negative 

Blood grouping and typing: 

       


CUE: 
    
      

USG - abdomen: 



Upper GI endoscopy: 




 Pulmonology , ENT and gastroenterologist opinions are taken 



Provisional diagnosis: 
Bronchiectasis 

Treatment: 
1)inj tranexa 1gm iv in 100ml NS 
2) inj tranexa 500mg iv sos 
3)inj optineuron 1 amp in 100ml NS  iv 
4)tab ethamsulate 250mg bd 
5)syp grillinctus 10ml po tid 
6)tab levocet 10mg OD hs 
7)monitor vitals

Follow up: 
Lobectomy was done 

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