General Medicine E log case series: 65 yr old male with Pulmonary Koch a/o uncontrollable DM-II

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🩺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. I am Nomika Alli (Roll no 179) of 6th Sem, MBBS.

A 65 yr old male R/O Mothkur came to the OPD on 9-12-2022 evening 8pm with chief complaints of chest pain radiating to shoulders a/o ribs pain, chest tenderness.

H/O cough, hemoptysis since 3 months.

H/O breathing difficulty.

H/O fever with chills from 8 months

H/O weight loss of 20kgs in 6months

H/O giddiness on waking up early in the morning from past 5yrs

H/O B/L -UL & LL tingling sensation since 5yrs

H/O chest & abdominal pain since 6 months

H/O Polyphagia, Polydipsia, Polyuria

H/O Nocturia++

HISTORY OF PRESENT ILLNESS:

This patient is 65 yr old male, farmer by occupation. He is apparently asymptomatic 5yrs back and developed B/L -UL &LL tingling sensation & numbness. He also has H/o giddiness on waking up early in morning . H/O fever with chills from 8 months. Fever is continuous, no diurnal variation, low grade .He lost 20kgs in the past 6 months and is having dizziness, chest and abdominal pain. He is having cough without sputum 6 months ago which progressed to hemoptysis since 3 months accompanied by cold and shortness of breath and also have breathing difficulty. Cough is productive, sputum copious, mucoid consistency, whitish yellow( sometimes blood tinged). Hemoptysis is decreased now which is bright red in color a/o clots. Post tussive vomiting ++

H/O dry mouth, Polyphagia, Polydipsia, Polyuria

Nocturia ++

Burning micturition

Difficulty defaecation, passes stools once in 3 days - constipation

appetite lost

Vomiting one episode after food everyday since 3 months

Decreased vision in both eyes since 5 yrs

All throughout his illness the patient was able to carry on with his daily activities and was going to work everyday. His daily routine is waking up at 4am in the morning, drinking tea at 6:30 am , having his breakfast as dosa/ upma/ idli at 8 am and leaving to work. He is going to have his lunch as rice with curry at 1 pm and continue with his work. He used to return home by 5 pm and have tea at 5:30 pm and his dinner as rice with curry at 7 pm. He goes asleep by 8 pm.

HISTORY OF PAST ILLNESS:

k/c/o HTN, DM-II since 10yrs. (on oral medication i.e; irregular)
Not k/c/o CVA, CAD, epilepsy, asthma, thyroid
No drug allergies

PERSONAL HISTORY: