50 yr old male patient came to hospital with cough,soreness of throat and tingling sensation
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50 yr old male patient complains of cough since 2 weeks ,tingling sensation in lower limbs since 3 yrs ,burning sensation of palms and soles since 3 yrs
HISTORY OF PRESENT ILLNESS
Patient was apparently alright 3 yrs back then he had shortness of breath which was insidious and progressed which was found to be pleural effusion for which he took medication. One and half year he had complains of fever which was low grade , intermittent cough which was whitish sputum with blood stains and then he was tested positive for tb and then he took antituberculosis drugs for 6 months and tested negative
Since 2 weeks he had cough with which is insidious in onset which was white in colour with no blood stain
HISTORY OF PAST ILLNESS
Tb since 1 year
No other known past history
PERSONAL HISTORY
Married
Diet : mixed
Bowels : regular
Micturition:normal
Apetite: lost
Habits :
Alochol regular since 25 yrs
Daily 20 cigarettes since 25 years stopped 4 years back
No known family history
PHYSICAL EXAMINATION
no pallor, icterus, cyanosis,clubbing of fingers or toes ,lymphadenopathy,edema of feet ,malnutrition,dehydration
Temperature:98.8F
Pulse:82/min
Respiration:18/min
Bp:110/80mmhg
Spo2:97%
Grbs:112mg%
SYSTEMATIC EXAMINATION
CVS
No thrills,cardiac murmurs
Cardiac sounds:S1 S2
RESPIRATORY SYSTEM
No wheeze,dyspnoea
Trachea position:central
Breath sounds:vesicular
ABDOMEN
Shape of abdomen:scaphoid
No tenderness,palpable mass,free fluid, bruits
Hernial orifice: normal
Spleen :not palpable
Liver:palpable
CNS
Patient is conscious
Normal speech
No neck stiffness , kerniks sign
INVESTIGATIONS
Chest X-ray
Serology
Renal function test
PROVISIONAL DIAGNOSIS
Upper respiratory tract infection
MEDICATION
For cough : grilinctus 15ml po tid
Tab. Augmentin 625mg po/bd 3 days
Tab. Azithromycin 500 mg po/od 3 days
Tab. Pan 40 mg po/od 3 days
Tab.meulomist 600mg po/ bd 3 days (glass of water )
Tab.beplex forte po/od 10 days
