1. MEDICAL CASE HISTORY OF A PATIENT
CASE NO:- 231
NAME:-S SIVA KUMAR AGE:-45years
SEX:- MALE REGION:-INDIA
RELIGION:-INDIAN INSURANCE:- NO
GARDIAN NAME:- KUMARI SUHANA
GARDIAN PH NO:-9581836463
COMPLIENTS OF PATIENT BY GARDIAN:-
Shortness of breath.
full cough and cold.
Raising in heart beat.
Legs and feet pains.
Rashes on legs.
2. HISTORY OF PRESENT ILLNESS
high fever dint stoped my medications.
Patient struggling at every breath.
Can’t breath properly.
Coughing with green thick phylem.
PAST MEDICAL HISTORY:-
Patient post hiv infected.
4months back is diagnosed with malariya.
Frequenty getting respiratory distress with cough.
Patient married 5years ago,after marrage he know he had hiv
positive, he has more sexuval parteners before marrage.
Patient is vegetarion.
He worked at taning industry since 7 years.
He is allergic for diclofenacim injection.
Allergic to pencillin.
Patient taking anti viral drug (abacavir).
Previsously used antibiotics.
Using reverse transe criptase inhibitertherapy.
3. PHYSICAL EXAMINATION:-
Weight:-70kgs height:-6 feet
Aappearence: - lean in body weight decreased.
Cyanoticface and legs,
Eyes red and lacrimationoccure,
Cough with poorphlegm,
Venus palpation:-jugularvenous palsationincreased
left intercoastal space shows murmur of tricuspid
x-ray of lungs:-
pruning of blood vessels in middle.
lead 2 peak P wave seen.
V1 large V wave.
in plex view left ventricles dilated,Pulmonaryartery
apicalview dilatedRV,RV hypertrophy.
In short axis RV hypertrophy,smallleft ventricle.
Right lung cathetarisation:-
35 mmhg at sleep
45 mmhg at physicalactivity.
diagnosised as:-pulmonary hypertention