A 65 year old male patient from Halia , nalgonda came to the OPD with chief complaints of bleeding from nose since one week

 Hi, I am Ananya Aleti  a 5th Sem Medical Student.This is an 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 patient's 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 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 a diagnosis and treatment plan. 

 CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CHIEF COMPLAINTS

 

A 65 year old male, from halia Nalgonda came to the OPD with c/o bleeding from nose since one week.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 1 week back . Then he developed bilateral nasal bleeding. It was sudden in onset, profuse  and subsided after taking medication. He later developed bleeding again after 1 day and is present up until now . It was  associated with small clots .

It was not associated with pain.

No headaches, vomitings

He had similar complaints 4 years back during summer season . It was about 2- 3 episodes. 

HISTORY OF PAST ILLNESS

No H/o HTN ,DM,CAD, TB,Asthma , epilepsy

No H/o blood transfusion

No surgeries were done in the past.

FAMILY HISTORY

Insignificant

PERSONAL HISTORY

Married

Farmer

Mixed diet

Normal appetite

Adequate sleep

Regular bowels 

Normal micturition

Alcohol - Regular 90ml since past 10 years

Beedi occasionally

No known allergies

GENERAL EXAMINATION

Conscious, coherent and cooperative

Malnourished 

Mild pallor

No icterus , cyanosis, clubbing of fingers, lymphadenopathy, pedal oedema.

Vitals

Temperature - 98.6F

Pulse rate - 90

Respiratory rate -20

BP-150/70mm Hg

GRBS-93 mg/dL

SpO2-99% 

Systemic Examination

No Tracheal deviation.

Chest bilaterally symmetrical

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No Tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- Mammary,Infra Axillary and Infrascapular- Decreased on both sides.

Percussion:                  

Resonant note on all areas 

Auscultation:

NVBS,BAE +

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

P/A:Soft ,Non-tender

CNS:

HMF-Intact

Memory -recent and remote:Intact

Speech-Normal

Cranial Nerves -Normal

Motor Examination-                  

Tone. UL. N. N

            LL. N.c

Abdomen 

 Shape – scaphoid, 

Umbilicus 

 Investigations