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case of a 45 year old male patient

Hello! This is likhita. M
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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. 

July 19

July 17
A 45 year old male patient, resident of verumurupalem who was a farmer by occupation presented to the hospital with 

chief complaints of 

- blood in the stools since 6months
    Had the same 1 month back
- shortness of breath and generalised      weakness since 1 month

History of presenting illness

The patient was apparently asymptomatic 6 months ago when he noticed blood after passing stool for 2 times with no associated abdominal pain of any type and recently noticed the same events a month back with no diarrhoea and pain

He also developed sob a month back which was of GRADE 3
he couldn't walk for a distance without feeling the shortness of breath. It seems to aggrevate on walking and relieved on laying down. 
Low grade fever, intermittent, now relieved
He also had generalised weakness since 1 month. 

Past history

He is not a k/c/o    DM, TB ,EPILEPSY, H/T CAD

Family history 

No significant history is noted

GENERAL EXAMINATION
Mild pallor
No icterus
no cyanosis
no clubbing

no pedal edema 
And generalised Lymphadenopathy

Personal history


Diet : Mixed 

Appetite : Normal 

Bowel and bladder movements: Normal

Sleep adequate 

Addictions : he drinks a pack of ciggarettes (6 in each pack) . Is a smoker since 15 years

Daily routine 

He wakes up by 5.30 and goes to the field and puts water to his paddy field. 
Then he has his breakfast by 8.30 and goes to his field again to take care of it . Comes back and has his lunch at 12 and then goes back again and comes to have tea at 4 and then has dinner at 9 . 


Vitals
Temp:98.5°F 
Bp: 120/80 mmhg 
PR: 90 bpm
RR: 19 cpm


Systemic examination
Cvs : 

Precordium normal 
No thrills ,
On auscultation 
S1,S2 heard ,no murmurs 

CNS: 
Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent

Respiratory system: 

Shape of chest:Bilaterally symmetrical

 Elliptical in shape

No visible chest deformities

No kyphoscoliosis,

Abdomino thoracic respiration, No irregular respiration

Trachea is central 

Auscultation: 

Normal vesicular breath sounds heard 

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