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CH.Snehitha

Roll no.31

5th semester

July 9, 2022

GENERAL MEDICINE.

CASE REPORT:

A 68 year old male patient farmer by occupation came to the OPD with chief complaints of itching all over the body since 45 days , cough and breathlessness since 10 days and knee pain. He also complaints of kidney problem. 

HISTORY OF PRESENT ILLNES :

Patient was apparently asymptomatic 2 years back then he developed flank pain, burning micturition, decreased urine output and hematuria. On visiting a local hospital, the doctor suspected renal problem on examining the x-ray that he ordered and prescribed some medication. Burning micturition was relieved after that. H/o shortness of breath aggravating on exposure to cold climate and relieved temporarily on medication. H/o knee joint pain since 7 years aggravating on work and relieved temporarily on medication. H/o itching all over the body aggravating on eating fish.

HISTORY OF PAST ILLNESS :

K/c/o HTN and DM type2 since 10 years and is on regular medication.

Met with an accident 2 years ago with minor injuries on the face, avulsion of tooth and rhinorrhoea.

No H/o TB, PREVIOUS SURGERIES, THYROID ABNORMALITIES, EPILEPSY, BLOOD TRANSFUSION 

TREATMENT HISTORY :

METFORMIN for diabetes 

TELMISARTAN for hypertension 

 PERSONAL HISTORY :

Married.

Occupation: Farmer (but stopped since many years), SARPANCH.

Appetite: NORMAL

Diet: MIXED

Bowel and bladder movements: REGULAR

Micturition: ABNORMAL.

Addictions: Regular consumption of alcohol (90ml daily) .

ALLERGIC HISTORY:

Allergic to fish.

FAMILY HISTORY :

Hypertension and Diabetes.

PHYSICAL EXAMINATION

• GENERAL EXAMINATION

Patient is conscious, coherent and co-operative

Well oriented to time, place, person.

Moderately built and Moderately nourished.

PALLOR - Yes

No signs of ICTERUS, CYANOSIS, CLUBBING OF HANDS AND FEET, LYMPHADENOPATHY AND OEDEMA.

VITALS

Temp- afebrile.

Pulse rate - 82 bpm.

Respiration rate-  /min

Bp-  140/90 mm hg

SYSTEMIC EXAMINATION 

CVS:

S1S2 ++

RESPIRATORY SYSTEM:

Dyspnoea - yes 

Position of trachea - central 

Breath sounds - vesicular 

ABDOMEN:

Shape of abdomen - scaphoid 

Tenderness - not 

Palpable mass- no 

Hernial orifices - normal 

Free fluid - no 

Bruits- no 

Liver- not palpable 

Spleen - not palpable. 

Bowel sounds - yes. 

CNS:

Level of consciousness- conscious 

Speech- normal 

Signs of meningeal irritation- none

PROVISIONAL DIAGNOSIS: CHRONIC UTRICARIA.

TREATMENT : TAB TECZINE 10mg OD × 2weeks.