A 50 years old male came to opd with cough and tingling sensation in lower limbs
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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 -
TREATMENT :-
Syp Grilinctus 15 ml
Tab Dolo 650 mg
Tab Neurobion forte
Tab Augmentin 625 mg
Nebulization Duolin
Monitor vitals.
