A 65 year old male from nalgonda came with complaint of bleeding from nose

Hi, I am Sravya , 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. 

CHIEF COMPLAINTS
 
Bleeding from nose since  1 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 .
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%

SYSTEM EXAMINATION

Respiratory system:

Inspection:

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.

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