GENERAL MEDICINE BLOG

CASE OF 61 YEAR OLD MALE

Greetings to one and all who are currently reading my blog.  This is Jasmisri,fifth semester medical student

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CASE:-

        A 61 yr old male daily wage labour came from Nalgonda presented to hospital 

CHIEF COMPLAINTS:-

Dry cough since 10days

Upperlimb pain since 10 days

Lower back pain since 10 days

Chest pain localised to left side since 10 days

Shortness of breath grade 2 since 3 days

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 3 years back 

 Involuntary movements of right upper limb from 3 yrs

Taking time to recall things for atleast 15 mins since 20 days

Right upper limb pain since 10 days which is  of dragging type ,slightly relieved on medication

Lower back pain since 10 days radiating downwards relieved on sleeping

Chest pain localised to left side since 10 days

Dry cough since 10 days

Shortness of breath on excertion and in supine position (orthopnea) since 3 days

HISTORY OF PAST ILLNESS:-

10 days back he suffered with fever which is relieved on medication

No history of diabetes, hypertension,TB, asthma,epilepsy,CVD

PERSONAL HISTORY:-

• Appetite- decreased
• Diet-mixed
• Sleep-normal
• Bowel and bladder movements-normal
• Adductions-Alcohol and tobacoo stopped 1 yr back

FAMILY HISTORY:-

No significiant family history

GENERAL EXAMINATION:-

The patient is conscious, coherent and well oriented to place,time and person

• Pallor
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• No Pedal edema
• Raised JVP 

Vitals:-

• Temp- afebrile
• PR:81BPM
• Bp:110/80 mm Hg

INVESTIGATIONS:-

Serum Iron:-

Ferritin:-

Complete blood picture:- on 5/09/22

Serum electrolytes :-

Serum creatinine:-

Reticulocyte count:-

LFT:-

HIV:-

LDH:-

Complete blood picture on 06/09/22

Impression :-Dimorphic anemia with leukocytosis with reactive

HBsAg:-

Dengue antigen:-

Blood urea:-

Random Blood sugar :-

Blood grouping:-

HCV antibodies:-

ECG:-

Dopler 2D ECHO:-

USG:-

Chart:-

PROVISIONAL DIAGNOSIS:-

PROVISIONAL DIAGNOSIS:-

BICYTOPENIA WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?) 

MODERATE SPLEENOMEGALY

TREATMENT:-

05/09/22
Rx
Tab AUGMENTIN 1.2gm/IV/BD
Tab AZITHROMYCIN 500mg/PD/OD
Tab PANTOPRAZOLE 40mg/PD/OD
Inj OPTINEURON 1 amp in 100ml of NS/IV/OD
Syp ASCORIL-D 10ml/PD/TID

O6/09/22
Rx
Tab AUGMENTIN 1.2gm/IV/BD
Tab AZITHROMYCIN 500mg/PD/OD
Tab PANTOPRAZOLE 40mg/PD/OD
Inj OPTINEURON 1 amp in 100ml of NS/IV/OD
Syp ASCORIL-D 10ml/PD/TID