55yr old with aspiration pneumonia and Parkinsonism

 June 20,2022

Hi, I am Ananya Nayak, 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 55 year old male patient,farmer by occupation resident of Nalgonda came to the casuality with the complaints of Shortness of breath and fever 6 days ago. 

HISTORY OF PRESENT ILLNESS-

The patient was apparently asymptomatic 10 days back.Then he developed shortness of breath and he was unable to eat and drink anything properly. He was diagnosed with Aspiration Pneumonia and Pulmonary Kochs.

Onset-insidious

Gradually progressive

Fever-on and off since 10 days,not associated with chills and rigor ,relieved on medication. 

Cough-since 6 months

A significant weight loss is seen and loss of appetite.

No case of chest pain,chest tightness,dizziness.

Ryles tube is used .

At first, he was admitted in pulmonology department then he was transferred to General Medicine department as he had complaints of weakness in 4 limbs -quadriparesis,more significant in left leg and hand.Decreased tone and power. 

Tremors was significant in his right hand.

His family said that he had complaints of tremors since 2 years but it aggrevated before 10 days.

Cannot sit and stand on their own,there is a whole body weakness and he was unable to lift anything.Rigidity is seen in 4 limbs.So Parkinsonism is suspected.

C/o painful lesions on both the feet.

No c/o itching

Diagnosed with friction blister.

As he has been  bedridden for 25 days,he has developed bed sores in the gluteal region.

HISTORY OF PAST ILLNESS-

Tremors was seen. 

He had a kidney problem.

FAMILY HISTORY-

No c/o asthma,hypertension, diabetes seen

No such significant family history seen.

PERSONAL HISTORY-

Married 

Appetite-lost

Diet-Non veg

Bowels-regular

No allergies 

Alcohol-occasional,stopped 2 years back

Smoking-yes,stopped 2 years back

NEGATIVE HISTORY-

No h/o TB,HTN,CAD,Epilepsy ,asthma

No headache 

GENERAL EXAMINATION-

Poorly nourished and built

Pallor-yes

Icterus-no

Clubbing of fingers-no

No cyanosis 

No lymphadenopathy 

VITALS-

Temperature-afebrile

Pulse rate -100/min

Respiration rate-30/min

Bp-110/80 mm of Hg

SpO2-98%

 

SYSTEMIC EXAMINATION-

RS-BAE+

CVS-S1,S2 +

PA-Soft,non tender

CNS-NAD

INVESTIGATIONS ORDERED-

CBP,Chest XRAY,ECG,2-D ECHO,CUE,LFT,RFT