75 year old male for blood transfusion

 MEDICINE CASE DISCUSSION

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 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 centred online learning portfolio and your valuable comments on comment box is welcome

M Rambai ,9th semester

Roll number 78 

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 a diagnosis and treatment plan. 

CASE

75 yr old male resident of Nampur ,farmer by occupation,came for blood transfusion on 23.3.2022.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 years back ,then he developed cough which was sudden in onset and gradually progressive ,cough was associated with sputum which is non blood stained.

So he went to a local hospital and took chest x-ray,where they found a radiodense mass, diagnosed as lung adenocarcinoma ,so he came to our hospital for treatment.

But we referred to him higher centres ,as there are no facilities here.

So patient went to Hyderabad hospital and was operated.

After then patient stopped going to work and stayed at home .

5 months back , patient again developed cough and shortness of breath which was of grade 2 and progressed to grade 3 ,so his family took him to hospital suspecting COVID 19,but after doing an x-ray found a mass diagnosed as malignancy