65M Severe cough and weakness PaJR

 E-LOGS MEDICINE 

Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centred approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.

A 65-year-old male, a toto driver in profession, presented with the complaint of -

• Cough for 2 months
• Generalized weakness for 2 months and
• Anorexia for 1 week

History of presenting illness:

The patient was reasonably well 2 months back. Then suddenly he developed coughing. The cough is mild in the morning, moderate in the afternoon, and got severe at night. Once he starts coughing, it persists for almost 2-3 minutes at a stretch. He also added that the cough was exaggerated when he lied.

The cough was wet in nature earlier but for the last 10 days, it become severe and turned into a dry cough. Following a severe cough, he feels pain in his chest and upper back region(in the spine).

The patient also complains that he feels weakness for the last 2 months, due to this exaggerated coughing.

He also complains of anorexia for 1 week.

Though he was normotensive, but recently often he becomes hypertensive due to stress.

History of past illness:

No significant past illness

Personal history:

He used to smoke for more than 30 years. (Over 20 cigarettes per day)

Clinical image: