61 yr old male with SOB and involuntary movements of both upper limbs

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment.

5 September 2022

M.G.Prasanna Lakshmi

Roll no 93 (2k18 batch) 

Case - 

A 61 y/o male, resident of Dubbaka, Ramanapet 

came to the OPD with chief complaint of SOB since 10 days. 

History of presenting illness-  

Patient was apparently alright 3 yrs back then he developed b/l involuntary movements which are asymmetrical(more on right side) and of lesser amplitude and intensity and frequency.

15 days back he developed fever which is of high grade,  intermittent in nature and not associated with chills and rigors. He was treated by the local doctor and the fever subsided in 3 days. 

H/o dry cough since 10 days which is more at night on lying down.

H/o generalized weakness and decreased appetite since 10 days.

H/o SOB since 10 days.( class 2)

H/o burning sensation in the chest during night which is relieved on taking food since 10 days.

He went to private hospital yesterday afternoon where he was diagnosed to have pneumonia.

Past history- 

He is not a k/c/o diabetes,hypertension, tuberculosis, asthma, epilepsy, leprosy, CAD, CVA 

Personal history- 

Diet -vegetarian

Appetite -decreased since 15 days

Sleep -decreased 

B&B movements-regular

Addictions - started consuming alcohol 2 years back(after demise of his wife) and then stopped consuming since 1 year(due to the fear of alcohol affecting his health).

Family history- 

No significant family history 

GENERAL EXAMINATION :-                                       patient is conscious,coherent and cooperative,well oriented to time place and person.

He is moderately built and nourished.

Pallor - absent

Icterus absent

Cyanosis - absent

Edema of feet - absent

Lymphadenopathy - absent

Clubbing - absent

VITALS:

Temperature: 100 F

BP: 140/80mmhg 

  PR: 112 bpm 

 RR : 18CPM

SYSTEMIC EXAMINATION:

CVS - S1, S2 heard , no murmurs 

Apex beat localised at 5th ICS

RESPIRATORY SYSTEM-

Position of trachea is central 

Shape of chest - cylindrical 

BAE present  

Breath sounds - Crepts heards at rt infra clavicular, mammary and infra mammary regions and lt mid axillary and infra scapular regions 

ABDOMINAL SYSTEM- soft , non tender and mild hepatosplenomegaly 

CNS - 

Oriented to time, place and person

Able to recall events but there is delay in response 

Speech is normal

No cranial nerve deficits 

No loss of power 

Tone - more increased on right upper limb 

??Cog wheel rigidity

Hyper reflexia of biceps, triceps, supinator

2+ for knee reflex

Absent b/l ankle reflex

B/L plantar withdrawal +

Palmomental reflex +

Tremors in both upper limbs &/ hands which is coarse and static 

PROVISIONAL DIAGNOSIS -

BICYTOPENIA UNDER EVALUATION

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH (BILATERAL LOWER LOBE CONSOLIDATION) PARKINSON'S(?)WITH 

MODERATE SPLEENOMEGALY

TREATMENT -

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ OPTINEURON 1 amp 100 ml /NS

Vital monitoring

Temperature monitoring