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A 31 yr old male presented to opd native of west bengal with chief complaints of excessive sneezing since 2yrs
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 yrs back
Then had excessive sneezing in early morning on exposure to cold which was continuous and when he takes water .Patient visited local hospital then he was on medication.Patient also says that his sneezes subsided only on taking medication(montelukast). Also complaints of difficulty in breathing and gets better upon pushing his nasal septum to the other side
Patient had history of trauma in his childhood and also epistaxis.He is allergic to egg and masoor dal.
Patient also complaints of itchy skin lesions over his groin since 4 yrs.The patient also complaints of decreased hearing and ringing in his ears since 6 months.Patient also complaints of not fully voiding of his stools . He says he is having fullness of stomach
He also has history of acidity problem since 7 - 8 yrs back and medication ( pantoprazole)
PERSONAL HISTORY
Diet is mixed
Sleep is adequate and snoring when sleeping
Bowel and bladder movements are regular
He has habit of alcohol consuming occasionally since 7 yrs
FAMILY HISTORY
His father has similar complaints of sneezing upon exposure to cold
PAST HISTORY
In 2004 due severe abdominal pain. Appendicitis patient underwent appendectomy and 2011 he had discharge from his ear underwent tymanoplasty and again in 2016 and 2018 he underwent surgery for piles. There is no history of hypertension and diabetes mellitus.
GENERAL EXAMINATION:
Patient was concious coherent and coperative well oriented to time place and person.
- No pallor
-No clubbing
-No cyanosis
-No icterus
-No generalized lymphedenopathy
-no pedal edema
VITALS
Temperature : afebrile
Pulse rate: 78 beats per min
Respiratory rate : 18 cycles per min
Bp :110/ 80mm of Hg
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
Itchy skin lesion over the groin
Investigations
Provisional diagnosis - Allergic rhinitis
Tinea corporis of cruris
Treatment
Otrivin nasal drops
Tab. Levocet 5 mg
Lucifin cream
tab leczin od 2 weeks
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