medical case history of a patient of acute silicosis

1. MEDICAL CASE HISTORY OF A PATIENT
BIODATA
CASE NO:- 231
NAME:-S Mahesh kumar AGE:-45years
SEX:- MALE REGION:-INDIA
RELIGION:-INDIAN INSURANCE:- NO
Wife:- rangamma
GARDIAN PH NO:-9581846469
ADRESS:- HNO-1-111/21,
Gandhistreet,
MADANAPALLI.
ADMISSION DETAILS
DATE:-1/12/2018 DAY:-monday
TIME:-8;30PM ADMITTEDBY:-wife
COMPLIENTS OF PATIENT BY WIFE:-
 Shortness of breath.
 Persistent cough and cold.
 Chest pain.
 Raising in heart beat.
 Legs and feet pains.
 Loss of waight

2. HISTORY OF PRESENT ILLNESS
 high fever dint stoped my medications.
 Patient struggling at every breath.
 Can’t breath properly.
 Suffering for breathing.
PAST MEDICAL HISTORY:-
 Patient post hypertensive disease
 4months back is diagnosed with malariya.
 Frequenty getting respiratory distress with cough.
FAMILY HISTORY
Patient married 15 years back,hisfather is worked at coal
mining industery
SOCIAL HISTORY:-
Patient is vegetarion.
He worked at glass cutting industry since 7 years.
ALLERGIES:-
He is allergic for diclofenacim injection.
Allergic to pencillin.
MEDICATION HISTORY:-
 Patient taking normal corticosteroids and betnosal inhaler
PHYSICAL EXAMINATION:-

3. Temperature:-99°f BP:-180/85
Weight:-70kgs height:-6 feet
Pulse:-85B/min
Inspection:-
Aappearence: - lean in body weight decreased.
Cyanoticface and legs,
Eyes red and lacrimationoccure,
Skin and lipsblue in colour
Feet swelling,dyspnea
Forced breathing,ortopneaposition.
History:-
He is working at coal industry he don’t used any mask at
work due to neglegency .
Percussion:-
Lungs:-tympanic sound in upper lobe of right lung,normal
sound at left lung(clearsound)
Heart:-normal sounds(dull)
Kidneys:-normal(dull)
Palpation:-
Lungs:-cage like chest,right upper lobe pain ful.expansionof
right intercoastal space
Heart:-normal

4. Kidneys:-normal
Auscultation:-
Lungs:-wekaning of vesicularon right side.
Heart:-normal.
LAB INVESTIGATION:-
COMPLETE BLOOD COUNT:- normal observed
RBC{ERETROCYTES} 4.6-6.4mil/cu 4.5mil/cu
HB% 10mg/ml 11mg/ml
Mean corpucellsvol{MCV} 78-97fl/ml 79 fl/ml
Leucocytes 4000-11000mm/cu 55000mm
differential wbc count:-
 Neutrophils 60-75% 69%
 Lymphocytes 20-30 % 26%
 Monocytes 2-8 % 8%
 Eosinophils 1-6 % 80%
 Basophils 0-4 % 2%
Platelets 150000-250000 cl/mm 156000cl/mm

5. INSTRUMENTATION:-
Oxymetry:-
65mg----normal (99-100 mg)
x-ray of lungs:-
infiltrate on right upper segment.
ECG:-
normal

6. ct scan:-

7. diagnosised as:- acute silicosis.
refered by:-
drpavan kumar,
CASS medical hospital,kalikiri.