Title:- 60 years man with Right pneumothorax and was earlier admitted for sinus pain, severe anemia and diabetes since 20 years
Disclaimer:-
This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.
A 60 year old man was admitted to the hospital with chief complaints of pain around the eyes, base & margins of the nose & back of the head, along with severe anemia.
The pain has been a consistent problem for the last 5 years. Earlier it was a mild pain but has increased gradually over the time. Pain is mostly stimulated by colder objects and dust. Recently the pain has been observed to increase on sudden exposure to sunlight & music at high level induces the pain.
Complaints of dizziness vomiting and nausea were also present. Breathing problems may be present as the patient was not able to speak at lengths and had to be given considerable time to speak.
There is no fixed duration and onset of pain.
The patient is also suffering from Diabetes DM 2 since 10 years for which he is currently on Insulin
BP has been normal.
No history of Epilepsy and TB
His elder brother had similar problems of headache and his sister is also diabetic.
Parents had diabetes.
No drug allergy or allergy from other substances. The patient does not smoke.
No history of blood transfusion.
Clinical findings were suggestive of severe anemia and on investigations the Hb was 3 g%
A CT paranasal sinuses done outside were suggestive of a mass in his left maxillary sinus.
The patient was evaluated by the ENT team and a nasal endoscopy revealed blood and mucus in the left maxillary sinus which was drained but no smear for gm stain or fungus was sent
The patient was treated further with Blood transfusion for his anemia and Insulin was continued for his Diabetes.
Readmission with right pneumothorax
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