50 yr old male came to OPD with cough and tingling sensation in lower limb

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. 


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