LONG CASE
Chief complaints-
A 71 year old male ,Mason by occupation came to the general medicine OPD on 1st June,2022 with chief complaints of
. breathlessness since 20 days
.cough since 20 days
.fever since 4 days
Daily routine-
He is Mason by occupation since 25 years.Daily he used to wake up at 7 am and goes to work by 9 am and return home at 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.
Timeline-
History of present illness-
Patient was apparently asymptomatic 2 months back,then he developped breathlessness which is insidious in onset, gradually progressive(MMRC grade-1) and dry cough.
=>2 months back,he visited near by government hospital where he was given medication.The symptoms were on and off with medication.
=>20 days back breathlessness was progresses to MMRC grade-2 to 3
.Associated with wheeze
.Aggrevated on cold exposure,exertion
.Relieved on rest
.No orthopnea and PND
=>20 days back,he developped cough with expectoration
.Mucoid in consistency
.Non foul smelling
.Non blood stained
.Aggrevated at night
=>4 days back,he developped fever,which is continuous and low grade
.Evening rise of temperature is present
.Relieved on medication
.Not associated with chills and rigors
History of past illness-
.No history of similar complaints in the past
.Not a known case of TB,Asthma,covid-19,Hypertension,Diabetes mellitus,COPD.
Personal history-
.Diet-mixed
.Appetite-decreased since 2 months
.Sleep-adequate
.Bowel movements-regular
.Bladder movements-decreased flow of urine since 15 days associated with burning sensation
.Addictions-smoking since 2yrs (4 beedies per day)
Drinks toddy from 22yrs of age (1 litre per day)
.Stopped smoking and alcohol intake since 2 months.
Family history-
.No history of similar complaints in the family members
General examination-
Patient is conscious, coherent , cooperative.well oriented to time, place and person
He is thin built and moderately nourished.
.Weight-34 kgs
.Temperature-99°F
.Pulse rate-83 beats per minute
.Respiratory rate-20 cycles per minute
.BP-120/80 mm of hg
.SpO2-95%at room air
.GRBS-108mg/dl
.Pallor- absent
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- absent
Systemic examination-
Respiratory system-
Inspection-
.Shape of chest-bilaterally symmetrical,elliptical
.Trachea- shift to right side
.Chest movements-decreased on right side
.No kyphosis and scoliosis
.No crowding of ribs
.No scars,sinuses,visible pulsations,engorged veins
.No drooping down of shoulders
.No supraclavicular and infraclavicular hollowing
.No intercoastal indrawing
Palpation-
.All inspectors findings are confirmed
.No local rise of temperature and tenderness
.Trachea-shift to right side
.Chest movements- decreased on right side
.Chest expansion-decreased on right side
.AP diameter-30cm
.Transverse diameter-23cm
.Hemithorax diameter on right side is less than that on the left side.
Percussion-
.Dull note heard on right upper part of chest
.vocal fremitus- reduced on apical part of right side of chest
Auscultation-
.Normal vesicular breathsounds heard
.Decreased breath sounds on right upper lobe
.crepitations present on right mid axillary area
.Vocal resonance- reduced on right apical area
CVS-
.S1 and S2 heard
.No murmurs
Per abdominal examination-
.Shape of the abdomen- scaphoid
.Hernial orifices- normal
.Soft,non tender,no organomegaly
.Bowel sounds- heard
CNS-
.Speech- normal
.cranial nerves- normal
.Motor system- normal
.Sensory system- normal
.Reflexes-normal
.Gait- normal
Provisional diagnosis-
Right lung upperlobe fibrosis
Investigations-
CBP-
CUE-
LFT-
2D echo-
ECG-
HRCT-
HBS-Ag-
HIV-
Hepatitis-C-
AFB Culture-
RFT-
.Urea-31 mg/ dl
.Creatinine-0.9
.Uric acid-3.1
.calcium- 10
.phospate-3.3
.sodium-128
.chlorine-95
.potassium-4.2
ABG-
.pH-7.44
.pCO2-34.3
.pO2 -68.3
.HCO3-23.4
.Needle thoracocentasis was done on 5 th June,2022.
.Under ultrasound guidance
.Fluid aspirated was 20 ml
.Straw coloured
Final diagnosis-
Right lung upperlobe fibrosis
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
2/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 102 bpm
RR-26 com
SpO2-90% on RA
98% on 2 lit oxygen
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
03/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 89 bpm
RR-26 com
SpO2-96% on RA
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
04/06/2022-
O/E - patient is conscious, coherent, cooperative.
Temperature-98.7°F
BP-120/80 mmHg
PR- 94 bpm
RR-14 com
SpO2-92% on RA
96% on 2 litres oxygen
Respiratory system examination-
Bilateral air entry- present
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
05/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 90 bpm
RR-24 com
SpO2-96% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
06/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
07/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
---------------------------------------------------------------------------------------------------
SHORT CASE
Chief complaints-
80 years old male patient, agriculture labourer by occupation came to general medicine OPD on 131 St may,2022 with the chief complaints of
fever - since 3 days
An episode of vomiting 2 days back
Decreased urine output since 2 days
burning micturition since 2 days
Timeline-
History of presenting illness-
=>patient is apparently asymptomatic 3 days back.
Then he developped fever
>insidious in onset
> gradually progressive
>No diurnal variations
>Relieved on medication
> Associated with chills, rigors
>Has generalised body pains
>It is not associated with cough, cold, shortness of breathe, night sweats.
=>He had an episode of vomiting 2 days back which consisted of food.It is non bilious and not foul smelling and colour is same as that of food.
=>He developped burning micturition 2 days back which is present at the start of the urinary flow and relieved after the urination.
=> He also developped decreased urine output since 2 days which is not associated with any hematuria.
=>He developped dyspnoea on exertion since 2 days.
Past history-
=>He has similar complaints in the past 10years ago
=>Then he consulted a local doctor and he was given medication.The symptoms were relieved on medication
=>From the past 10 years ,there is recurrence of such episodes
=>later he was refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and he was given some diuretics as he is suffering from decreased urine output(oliguria)
=>Even after dialysis,he developped recurrent episodes of fever with burning micturition.
=>He is a known case of hypertension since 24years.
=>Not a known case of diabetes mellitus, tuberculosis,asthma and epilepsy.
Surgical history-
=>He underwent nephrectomy surgery 27yrs ago =>He donated his left kidney to his brother.
Personal history-
.Diet- mixed
.Appetite - normal
.Sleep - adequate
.Bowel - didn't pass stools since 4 days
.Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
.Allergies- none
.Addictions- >3 beedi/ day from 27yrs of age
>Alcohol- occasionally
.Stopped both alcohol and smoking after nephrectomy surgery.
Family history-
=>No similar complaints were present in the family members.
=>No H/O DM,HTN.
General examination-
=>Patient is conscious, coherent, co operative and well oriented to time, place, and person.
moderately build and moderately nourished.
.Temperature-99.2°F
.Pulse rate-76 beats per minute
.Respiratory rate-19 cycles per mimute
.BP-150/90 mm of Hg
.GRBS-78 mg/dl
.SpO2-99% at room air
.Pallor- present
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- present( gradually progressive,pitting type,bilateral,grade-2,below knee present upto ankle region from below)
>Not relieved on rest
Systemic examination
Provisional Diagnosis:
=> No visible pulsations and scars,sinuses and swellings.
=>No abdominal distension
=> Soft, non tender, no organomegaley.
=>Umbilicus is inverted.
CNS EXAMINATION:
.Conscious
.Speech- normal
.Cranial nerves: normal
.Sensory system: normal
.Motor system: normal
.Reflexes- Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
.Gait-normal
Provisional Diagnosis:Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary track infection.
Investigations.
Complete blood picture-
On 31/05/2022,4.36 pm-
On 31/05/2022,11.03pm-
Hemogram-On 01/06/2022-
On 02/06/2022-
Hemoglobin - 6.6 gm/dl
Increased WBC count- 19,900
RFT-
Urea - 129 mg/dl
Creatinine- 6.3 mg/dl
Complete urine examination-
Urine - pus cells (plenty)
Blood urea-
Random blood sugar-
USG report: 1)Raised echo genicity of right kidney2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney
Serum iron-
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos.
01/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-99.2°F
.Pulse rate-76 beats per minute
.Respiratory rate-19 cycles per mimute
.BP-150/90 mm of Hg
.GRBS-78 mg/dl
.SpO2-99% at room air
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos.
02/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-98.6°F
.Pulse rate-90 beats per minute
.Respiratory rate-20 cpm
.BP-130/70 mm of Hg
.GRBS-148 mg/dl
.SpO2-99% at room air
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos.
03/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-99.6°F
.Pulse rate-94 beats per minute
.Respiratory rate-20 cpm
.BP-110/70 mm of Hg
.GRBS-132 mg/dl
.SpO2-99% at room air
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos
04/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-98.6°F
.Pulse rate-89beats per minute
.Respiratory rate-20 cpm
.BP-130/90 mm of Hg
.GRBS-122 mg/dl
.SpO2-98% at room air
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos
05/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-98.6°F
.Pulse rate-86 beats per minute
.BP-150/90 mm of Hg
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos
06/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-99.2°F
.Pulse rate-86 beats per minute
.BP-150/90 mm of Hg
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos
07/06/2022-
Patient is conscious,coherent and cooperative.moderately built and moderately nourished.
.Temperature-afebrile
.Pulse rate-84 beats per minute
.BP-130/90 mm of Hg
Treatment:
1)Inj. Piptaz -2.25gm/tid
2)Tab. Lasix -40ug/po/ bd
3)Tab. Zofer -4mg/po/ sos
4)Tab. Dolo -650/ po/ sos
5)Tab. Pan 40mg /po/ od
6)Nebi. Duolin and Budecort 6hrly
7)Syr. Mucaine gel 15ml/po/ bd before meal 15min
8)Syrup. Cremaffin 15ml/po/ sos
.jpeg)
Comments
Post a Comment