40 year old male patient with hemoptysis

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Here is the case I have seen:

A 40 year old male patient daily wage worker by occupation resident of nalgonda came to OPD with 

CHEIF COMPLAINTS:-

•Cough with blood since 3 days.

•Breathlessness since 2 days.

HISTORY OF PRESENTING ILLNESS:-

•Patient was apparently asymptomatic 2 days back then he developed cough with sputum which was mucopurulent, blood tinged ,non foul smelling 10 times a day about 10-15 ml associated with clots.

•Shortness of breath (grade 2 progressed to grade 3 associated with paroxysmal nocturnal dyspnoea)

• No complaints of chest pain ,fever.

HISTORY OF PAST ILLNESS:-

•In 2017:-

•He had a history of papillary carcinoma of thyroid for which he underwent total thyroidectomy and was on radiation therapy 4 years back.

•He has no history of similar complaints in the past.

•He is not a k/c/o DM, HTN, Bronchial Asthma, Epilepsy , Tb , CAD.

PERSONAL HISTORY:-

• Diet- Mixed

• Appetite - Normal 

• Sleep - Not adequate 

• Bladder and Bowel movements - Regular 

• Addictions - Smoker since 20 years 1 beedi/day stopped 4 years ago. 

GENERAL EXAMINATION:-

Patient is concious coherent cooperative

Well oriented to time, place , person 

Moderately built and nourished.

• No pallor 

• No Icterus

• No cyanosis 

• No clubbing 

• No Lymphadenopathy 

• No oedema

VITALS:- 

• Temperature:- Afebrile (98.6 F )

• Pulse rate - 110 bpm, regular 

• Respiratory rate - 28 cpm 

• BP - 100/70 mmHg 

• SpO2 - 98% on room air .

SYSTEMIC EXAMINATION:- 

CARDIOVASCULAR SYSTEM :-

INSPECTION:- 

• Chest is elliptical

• Trachea is central.

• No visible scars or sinuses .

• Movements are bilaterally symmetrical.

PALPATION:- 

• All inspectory findings are confirmed: Trachea is central , movements are bilaterally symmetrical.

• Antero- posterior diameter < Transverse diameter of chest 

• Apex beat felt at 6 th intercoastal space lateral to midclavicular line .

AUSCULATION:- 

S1 S2 heard 

No murmurs 

RESPIRATORY SYSTEM:-

INSPECTION:-

• Chest is elliptical in shape.

• Trachea is central. 

• Movements are equal bilaterally. 

• No scars or sinuses. 

• Apical impulse is not seen.

PALPATION:- 

• All inspectory findings are confirmed. Trachea is central , movements equally bilateral.

• No local rise of temperature

• No tenderness 

• Apex beat felt in 5 th intercoastal space lateral to midclavicular line.

PERCUSSION:- 

• Dull note heard over IMA bilaterally.

• Resonant note heard over all other areas.

AUSCULATION:-

 • Bilateral air entry present - Normal vesicular breath sounds heard.

• Crepts are heard bilaterally.

PER ABDOMEN:-

• Soft, non tender.

• No engorged veins / scars / sinuses .

CENTRAL NERVOUS SYSTEM:- 

• No focal neurological deficit.

PROVISIONAL DIAGNOSIS:-

• ? Heart failure.

•  Hemoptysis secondary to ? Lung metastasis.

• Pulmonary edema to ? Pulmonary venous hypertension.

INVESTIGATIONS :- 

ECG :- 

HEMOGRAM:- 

SERUM ELECTROLYTES:-

19-12-22

20-12-22

TROPONIN-I 

2D ECHO 

CHEST X-RAY

FINAL DIAGNOSIS

• ?Heart failure with reduced ejection fraction (30%).

TREATMENT

1. Tab.ALDACTONE - 50 mg/PO/OD

2. Inj. TRANEXA - 500 mg/IV/TID.

3. Syrup potklor 15 ml in a glass of water/PO/TID.

4.Tab. Carvedilol -25 mg /PO/OD

5. Salt restriction < 2 gm/ day

6. Fluid restriction < 1.5 lit/ day