61 yr old male with dry cough, dragging pain towards the finger tips,SOB,lower back pain and chest pain

 Sep 16

Hello, I am Y.N.Indu Vaishnavi,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.


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 - 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:


PROVISIONAL DIAGNOSIS

BICYTOPENIA UNDER EVALUATION
WITH
COMMUNITY ACQUIRED PNEUMONIA
WITH PARKINSONISM








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