General Medicine case study .

B.Divya
5th sem
Roll no 23



A male pt aged 50yrs a resident of Miryalguda  farmer by occupation was brought  to OPD by his son in law.
Cheif complaints
          Shortness of breath
           Burning micturition
          Headache
           Throat pain
 History of present illness
 
H/o shortness of breath since 1 yr
H/o headache since 20days( occipital region)
H/o neck pain since 1 yr.
H/o throat pain since 4days(pricking type)

History of past illness
No H/o DM,Tb, Epilepsy,CKD, cardiovascular accidents.
Cerebrovascular accident 25 yrs back.
H/o previous medication (joint pains, headache,neck pain, shortness of breath)
No H/o previous hospitalization.
Family History
His mother has Sob
Personal History
Married
Occupation-farmer
Appetite-normal
Diet-mixed
Sleeping habits:He has sleep alterations due to painsand discomfort.
Bowel- regular
Micturition- burning
No H/o allergy
Addictions- he smokes but stopped 2 yrs back.He smokes 4-5 cigerettes per day.He smoked for 40 yrs.
Physical examination
General Examination
No pallor 
No icterus
No cyanosis
No lymphadenopathy
No pedal odema
Pulse rate:118/min
Temp:afebrile
Respiratory rate:22/min
BP:100/60 mm/hg
SPO2:95%
Systemic examination
CVS
S1,S2 present
Respiratory system
BAG present
Abdomen
Scaphoid shape
No palpable mass
No tenderness
Slpeen not palpable
Liver not palpable
No free fluid
Bruits present
CNS
Conscious
Speech normal
Sensory system
Pain - +
Temperature-+
Touch-+
Position sense-+
Vibration+
Discriminative sensations+
Motor system:
Reflexes-normal
Gait-normal
Power-+5
Tone - normal
INVESTIGATIONS:


Urine Examination


HBsAg( Rapid)
Anti HCV antibodies (rapid)




Random Blood sugar
RFT


HIV-RAPID
LFT

HEMOGRAM

ABG

Treatment
8/6/2022
O2 therapy
TAB.Augmentin 625mg Twice daily
TAB.PAN 40 once daily morning before food
TAB.ZINCOVITonce daily 
9/6/2022
TAB.AUGMENTIN 625 mg BD
TAB.PAN 40mg OD
TAB.ZINCOVITOD
10/6/2022
TAB.AUGMENTIN
TAB.PAN40
TAB.ZINCOVIT
NEB.BUDECORT
NEB.DUOLIN

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