61 year male with BICYTOPENIA UNDER EVALUATION
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A 61 year old male resident of Ramulapeta,yadadri dist who is a daily wage labourer in construction work came to the hospital with complaint of
CHIEF COMPLAINTS
Dry cough since 10 days
Dragging pain towards the finger tips since 10 days
Lower back pain since 10 days
Shortness of breath Grade 2 -grade 3
Chest pain near heart since 10 days
HISTORY OF PRESENTING ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEAR AGO WHEN
He noticed involuntary movements of upper right limb at rest and decreased on movement
2 years ago his wife passed away because of which he became reclusive and increased intake of alcohol
1 year back he noticed showing of moments and decrease in his pitch of voice
He has used medication but stopped using after 5 months due to lack of improvement of symptoms
Since 20 days back he has trouble recollecting and takes at least 30-40 minutes if he wants to do something
Like bringing a article from home
Then 10 days back he experienced dry cough
Lower back pain on both sides draging type radiating towards the coccyx
Parn in upper right arm radiating towards the finger tips dragging in nature
Both of which were relieved on medication and rest
Chest pain more of a burning sensation since 10 days
Shortness of breath Grade 2 -3
Not relieved on rest
No association with vomiting or headaches
PAST HISTORY
10 days back had a episode of fever which subsided on medication
Not a known case of
Diabetes
Hypertension
Tb
Asthama
Epilepsy
Cvd
Chemotherapy
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - mixed
Appetite - Decreased
Bowel and bladder - adequate
Allergies -no
Addiction - after demise of wife he sought these
18 ciggarette per day and alcohol
Daily routine before 10 days
5:00 woke up
6-7:00 had breakfast
9:30 went to work
1:00 lunch
6:30_7:00 comes back and watches tv
8-9:00 dinner
9:30 sleep
Daily routine after 10 days
5:00 woke up
6-7:00 had breakfast
9:30 went to work
1:00 lunch
6:30_7:00 comes back and watches tv
8-9:00 dinner
9:30 sleep
Daily routine after pain
Stopped going to work
Still wakes up at 5 but then
Eats and sleeps
Sometimes watches tv
GENERAL EXAMINATION
Thin built and malnourished
Vitals
Temperature : Afebrile
Pulse: 81
BP:110/80 mm/ hg
RR :18
SPO2 : 97%
Pallor : present
Icterus present
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Pedal edema absent
SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs
ABDOMEN EXAMINATION
RESPIRATORY SYSTEM
No dyspnoea wheeze
Central trachea
Bilateral air entry +
Bilateral basal crepts +
CNS
Higher functions
Patient is conscious, coherent,and co operative
Patient is oriented to place not to time and person
Delay in response but able to recall
Examination of motor system
Tone increased on right upper limb
Not able to approximate both upper limbs
Power of muscle normal
Tremors : resting
pill rolling movement
Reflex
