CASE 3

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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

A 61 year old male resident of Ramulapeta,yadadri dist who is a daily wage labourer in construction work came to the hospital with complaint of

CHIEF COMPLAINTS
Dry cough since 10 days
 Dragging pain towards the finger tips since 10 days
Lower back pain since 10 days
Shortness of breath Grade 2 -grade 3
Chest pain near heart since 10 days

 HISTORY OF PRESENTING ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEAR AGO WHEN 
He noticed involuntary movements of upper right limb at rest and decreased on movement
2 years ago his wife passed away because of which he became reclusive and increased intake of alcohol 
1 year back he noticed showing of moments and decrease in his pitch of voice
He has used medication but stopped using after 5 months due to lack of improvement of symptoms
Since 20 days back he has trouble recollecting and takes at least 30-40 minutes if he wants to do something
Like bringing a article from home

Then 10 days back he experienced dry cough 

Lower back pain on both sides draging type radiating towards the coccyx 
Parn in upper right arm radiating towards the finger tips dragging in nature 
Both of which were relieved on medication and rest

Chest pain more of a burning sensation since 10 days 

Shortness of breath Grade 2 -3
Not relieved on rest 
No association with vomiting or headaches

PAST HISTORY

10 days back had a episode of fever which subsided on medication
Not a known case of
Diabetes 
Hypertension
Tb 
Asthama
Epilepsy
Cvd
Chemotherapy

FAMILY HISTORY
Not significant

PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -no
Addiction - after demise of wife he sought these
18 ciggarette per day and alcohol

GENERAL EXAMINATION
Thin built and malnourished 
Pallor : present 
Icterus present
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Pedal edema absent

Vitals
Temperature : Afebrile 
Pulse: 81
BP:110/80 mm/ hg
RR :18 
SPO2 : 97

SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs

ABDOMEN EXAMINATION

Examination of motor system 
Tone increased on right upper limb
Not able to approximate both upper limbs
Power of muscle normal
Tremors : resting
                 pill rolling movement
Sensory system : Normal 

INVESTIGATIONS:

Haemogram

Report 

PROVISIONAL DIAGNOSIS
BICYTOPENIA UNDER EVALUATION
WITH
COMMUNITY ACQUIRED PNEUMONIA
WITH PARKINSONISM


Comments

Post a Comment

Popular posts from this blog

CASE -7

Image
A 65 year old patient of farmer in occupation and resident of miriyalaguda came to the hospital with complaints  of fever, generalized weakness since 15 days and pain during swallowing since 3 days from which he came to hospital HOPI: Patient was apparently asymptomatic 15 days back then developed fever, insidious in onset, gradually progressive, high grade, intermittent associated with chills and rigours associated with generalised body pains  C/o vomitings- 1 episode, bilious, food as content non blood stained, non projectile.  H/o burning micturition 15 days back  No dysuria, frequency, urgency, hesitancy  No history of epigastric pain NO H/O CONSTIPATION. PAST HISTORY:   There was a history of pedal edema 15days back along with decreased urine output for which he was treated in hospital and was treated with antibiotics (piptaz for 5 days) following which both are resolved. NO H/O TB ,ASTHAMA, EPILEPSY, THYROID DISORDERS,BLOOD TRANSFUSIONS,DM,HTN   ...
Read more

CASE-4

Image
Hi I am Siddharth fifth semester medical student.This is an online e block to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.   A 35 yr male patient of carpenter in occupation and a resident of suryapet came to OPD with complaints of pain in the abdomen And SOB CHEIF COMPLAINTS: Pain in the abdomen since 3 months Occasional palpitations since 3 months shortness of breath since 1 month Generalized weakness since 10 days HOPI: patient was asymptomatic 3 months ago then Started developing palpitaions not associated with chest pain which is reduced on drinking alcohol. There is SOB which is of GRADE 1-2 Without association of orthopnea and PND Pain is sudden  in onset, non radiating , no aggregating on consumption of food or during an activity, no releaving factors  PAST ILLNESS: generalized weakness since 10 days Constipation is present  No HISTORY of Fever burning micturation Blood transfusi...
Read more