N.lavanya
Roll 93
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A 82 year old resident of Nalgonda came with
Chief complaints
Shortness of breath since 15 days
Cough since 15 days
History of presentating illness
The patient was apparently asymptomatic 15 days back and
developed shortness of breath which is gradual in onset non
progressive grade 2 type no aggrevating factors relived on
rest and No associated features
Cough since 15 days with sputum coupious amount white in
colour non blood stained and non foul smelling no
aggrevating and relieving factors . And no associating factors
Dizziness since 10 days
Past history
Not a known case of HTN DM Epilepsy Asthama
12 yrs ago had a attack of dengue chickenguniea and malaria
investigations RFTs was deranged for which 1 session of hemodialysis.
H/O ? viral fever 4-5 years ago and deranged which improved as fever subsided.
Left eye blindness right eye had cataract surgery 20 yrs back
Personal history
Decreased appetite
Adequate sleep
Passing of stools once in 2 days ( which was normal for the patient )
No allergies
Chronic smoker for 60 years
10 packs of cigarettes per day
Occasionally consumes alcohol
Daily routine
Patient wakes up at 7 am, gets freshened up and then
takes tea at 8 am and eats breakfast at around 10 am,
goes to spend time in the village with Neighbours,
comes back after an hour or two, has lunner at 1 pm
and then takes a nap for an hour or so,wakes up then
watches television for sometime, takes tea at around
5:30 pm, takes a stroll again in the neighborhood and
has dinner at around 9 pm and goes to bed by 10 pm.
Family History
In significant
Vitals-
BP-100/60MMHG
PR-57BPM
RR-20CPM
TEMP-AFEBRILE
SPO2-97% AT RA
Pallor is present
No features indicating the presence of icterus, cyanosis, clubbing, edema
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
INSPECTION
No distention,No scars
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
No local rise of temperature, Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.
PERCUSSION
Liver span is 12cm, No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.
AUSCULTATION
Bowel sounds present.
CVS- S1 and S2 heart sounds heard, no murmurs
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
CNS EXAMINATION
Right Handed person, uneducated
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
MMSE 26/30
speech : muffled, unclear
Behavior : normal
Memory : Intact.
Intelligence : Normal
Lobar Functions : Normal.
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
Intact
MOTOR EXAMINATION:
Right Left
BULK UL Normal Normal
LL Normal Normal
TONE UL Normal Normal
LL Normal Normal
POWER UL 5/5 5/5 LL 5/5 5/5
REFLEXES
Right Left
BICEPS ++ ++
TRICEPS ++ ++
SUPINATOR ++ ++
KNEE ++ ++
ANKLE ++ ++
PLANTAR flexor flexor
SENSORY EXAMINATION: intact
PROVISIONAL DIAGNOSIS
?UPPER RESPIRATORY TRACT INFECTION
? TUBERCULOSIS
? GASTRITIS
INVESTIGATIONS
COMPLETE BLOOD PICTURE
HB- 13.2gm/dl
Total count-7,600 cells/cumm
Platelets-2.32lakhs/cumm
Smear-Normocytic normochromic
Serum creatinine-2.1mg/dl
Blood urea- 55mg/dl
RBS-99mg/dl
Serology is non reactive for Hbsag,HBV and HIV
Chest x ray
B/L. Renal cortical cysts
Complete urine examination
Upon investigations patient was found to have
CHRONIC KIDNEY DISEASE which may have been
after the attack of ? malaria? Chikungunya 10 years back.
And probably resolving
TREATMENT
TAB.AZITHROMYCIN PO/OD
TAB.PANTOP 40MG PO/OD/BBF
TAB.DOLO 650 MG SOS
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