A 50 years old male came to opd with cough and tingling sensation in lower limbs

28 November, 2022

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 .

CHIEF COMPLAINT :-

Patient complaints of cough, soreness of throat and tingling sensation of lower limbs since 10 days. 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 10 days back. Later he developed shortness of breath, cough which was insidious in onset with whitish colour sputum, non blood stained. He also developed tingling sensation in lower limbsand burning sensation of palms and soles. 

HISTORY OF PAST ILLNESS :-

No history of HTM/DM

No history of asthma

History of Tb 1 and half yrs back. 

PERSONAL HISTORY :-

Diet - Mixed

Sleep - Normal

Appetite - Lost

Addictions - 

     Alcohol - Regular alcohol, 20 days back he took alcohol 60ml each day for 15 days

     Smoking - 4 years back 20 cigarettes per day for 25 years

Allergies - None

Bowels - Regular

Micturition - Normal

FAMILY HISTORY :-

No relevant family history. 

GENERAL EXAMINATION :-

Patient is conscious ,coherent ,cooperative well orientated to time ,space and person.

No pallor ,cyanosis ,lymphadenopathy, icterus ,clubbing ,oedema

VITALS :-

    Temperature - 98.8°F

    Pulse rate - 82 bsats/min

    Respiratory rate - 18 cycles/min

    BP - 110/80 mm Hg

    Spo2 - 97%

     GRBS - 112 mg%


SYSTEMIC EXAMINATION :-

CVS -S1,S2 heard.

RESPIRATORY SYSTEM -No dyspnoea, wheeze present. Central position of trachea. 

ABDOMEN -Scaphoid shape,No tenderness,No palpable mass

Bowel sounds present

CNS -No focal neurological . 

INVESTIGATIONS :-

Hemogram, chest x ray, RFT, serology tests done. 

Hb - 11.3

PCV - 33.3

TLC - 13,600

RBC - 4.04

Platelet count - 4.0 lakhs

Blood urea - 36

Serum creatinine - 0.9

T. Bilirubin - 1.23

SGPT - 11

SGOT - 8

T. Protein - 6.8

Albumin - 3.5

ECG -


PROVISIONAL DIAGNOSIS :-
            Upper Respiratory tract infection

TREATMENT :-

Syp Grilinctus 15 ml

Tab Dolo 650 mg

Tab Neurobion forte

Tab Augmentin 625 mg

Nebulization  Duolin

Monitor vitals. 


Popular posts from this blog

A 50 years old male came to casuality with knee pain

Image
March 19, 2022 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 avakeilable 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 . A 50 years old male who is a farmer came to casuality with knee pain since 1 year. The pain was insidious in onset and is gradually progressive.  HISTORY OF PRESENT ILLNESS :- Patient was apparently asymptomatic 4 years back. Then he developed knee pain. The pain was insidious in onset and is gradually progressive. He has severe knee pain and pedal edema since 6 days and was admitted in the hospital. He was diagnosed with hyperuricemia and anemia under evaluation. 
Read more

GENERAL MEDICINE : A 46 year old male

Image
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 . A 46 year old male who is resident of Bhongir and by occupation a Barber came to OPD on 11th of January at 4:10 pm. CHIEF COMPLAINTS :- A 46 year old male complaints of :- - Intermittent fever since 12 days - Loss of appetite since 12 days - Pedal edema since 7 days - Shortness of breath since 7 days - Jaundice since 7 days HISTORY OF PRESENT ILLNESS :- Patient was apparently asymptomatic 12 days back.Then he complained of fever which is low grade, intermittent, on and off episodes a
Read more

A 54 years old male with renal calculi in right kidney

Image
March 11, 2022 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 . A 54 years old male came with a chief complaint of renal calculi in right kidney.  HISTORY OF PRESENT ILLNESS :- Patient was apparently asymptomatic 1 year back. Then patient developed pain in right loin. The he went to the hospital. He was on ayurvedic medicine for few days. And then he developed pain 1 month back and was admitted in the hospital.  He has no history of pyrexia, graveluria, hematuria.  HISTORY OF PAST ILLNESS :- Patient has a history of hypertension si
Read more