61 yo male with Bicytopenia, CAP

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DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT : 

An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references

Documentation :

is being done on 6th of september 2022

(Updates will be done later in the future with dates mentioned for the same)

 My patient is a 60 year old man , resident of ramulapeta, who is a daily wage labourer in construction work.

 1. SOB on exertion ( SOB after walking for <500m ) since 30 days
 2. dry cough since 2-3 days
3. H/O fever 2 weeks back lasted for 1 week
4. C/O burning sensation in chest since 3 days
5. c/ O involuntary movements of Rt. upperarm since 3 years

History of presenting Illness

Pt. was asymptomatic till 2 weeks back then he had developed fever which lasted for 1 week and which was relieved on medication. Since 3 days patient had developed difficulty in breathing on supine position and burning sensation in chest. 

History of past illness

Not a k/c/o DM / HTN / CVA / CAD / TB / Asthma / Epilepsy.

Personal History

He is married and is a farmer by occupation
He consumes mixed diet
Appetite is normal
Bowel movements are regular
He stopped consuming alcohol 2 years back
He also stopped tobacco consumption 2 years back

Family History
No relevent family history

General Examination

Vitals 

Pulse: 81 bpm
Blood Pressure: 110/ 80 mm Hg
Temperature: Afebrile
Respiratory Rate:

Pallor -
Icterus -
Cyanosis - 
Clubbing -
Lymphadenopathy -
Edema - 

Systemic Examination

Patient is c/c/c 

CVS : S1 S2 +
R/S : 
Trachea central
Vesicular breath sounds heard 
Rhonchi / Rales heard 
P/a : soft Nt

CNS 

Patient is conscious, coherent and cooperative, oriented to time , place.

Delay in response but able to recall

         RL TONE UL           LL           
POWER UL /5 /5

                   LL /5 / 5 
 

REFLEXES

                          R L

    Biceps 2 + 2+

     Triceps 2+ 2+

     Supinator 2+ 2+

       Knee 2+ 2+ 

Babinsky sign : positive

Coordination of movement 

Finger nose test: normal

Gait

Tremors : resting

pill rolling movement

Sensory system :Normal

Investigations ordered : 

Hemogram 
BGT
CUE
RBS
Sr. Urea
Sr. Creatinine
Sr. Electrolytes
LFT
Serology - HIV, HbsAg, HCV 

ECG 
2D Echo
C. XR - PA
Dengue 
ESR 
Mp Strip test 
Peripheral Smear


S. Ferretin
S. Fe
Retic count
S. LPH


Provisional Diagnosis: Community Acquired Pnuemonia
(with left lung consolidation) 

? Parkinson's 

INVESTIGATIONS 

HEMOGRAM 


LIVER FUNCTION TEST
SERUM ELECTROLYTES
RANDOM BLOOD SUGAR
BLOOD UREA 


SERUM FERRITIN 

SERUM IRON

SERUM CREATININE
Blood Group : O +ve
NS1 Antigen : -ve

TREATMENT HISTORY

Day 1 

[No IV Fluids]

1. Inj. AUGMENTIN 1.2 gm/ IV / BD
2. Tab. AZITHROMYCIN 500 /P0 / OD
3. Tab. PANTOPRAZOLE 40/ PO / OD
4. Inj. OPTINEURON 1 amp in 100 ml NS / IV / OD 
5. Further treatment, Based on anemia workup
6. Syp. ASCORIL -D 10 ml /PO / T ID

Day 2 

1. Inj. AUGMENTIN 1.2 gm/ IV / BD
2. Tab. AZITHROMYCIN 500 /P0 / OD
3. Tab. PANTOPRAZOLE 40/ PO / OD
4. Inj. OPTINEURON 1 amp in 100 ml NS / IV / OD 
5. Syp. ASCORIL -D 10 ml /PO / TID



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