1701006069 CASE PRESENTATION

 LONG CASE 

A 46 year old male came to the casualty with complaints of drowsiness

Vitals at admission:

BP: 110/80 mm of hg

HR: 98bpm

RR: 18cpm

Temperature: 101 degree farenheit

SpO2: 98% on RA

GRBS: 124 mg/dL

General Examination:

Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No visible signs of dehydration

Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: Bilateral air entry is present.

       Normal vesicular breath sounds are heard

P/A: Soft, Non tender

CNS: 

Patient is having altered sensorium

.Cranial nerves- intact

.Motor system- normal

.Sensory system- normal

Reflexes:

Biceps

Triceps

Supinator

Knee

Ankle

Plantar

All are normal

Power- 5/5 in both upper and lower limbs

Tone- nomal in both upper and lower limbs

Meningeal signs are not seen

Investigations:

On admission 

19.5.22

20.05.22

LDH- 192

21.5.22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.05.22

 

Culture report: Klebsiella Pneumonia positive

2D Echo:

24.2.22

Patient Complained of Sudden diminision of vision in right eye 

Sent for ophthalmologic examination

Diagnosed as secondary angle closure glaucoma 

Treated with timolol bd for 1 week and glycerol 5times daily for 1 week

25.5.22

27.5.22

Hb- 7

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

30.05.22

07.06.22

Provisional Diagnosis: 

Right emphysematous pyelonephiritis  Left acute pyelonephiritis  Encephalopathy secondary to sepsis.

Treatment:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

Day 11:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000

INJ. COLISTIN 2.25 MU IV OD(Day 5)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

On 7.6.22

IV fluids 50ml per hr

INJ. RANTAC 50mg IV OD

INJ. ZOFER 4mg IV TID

INJ. LASIX 40 mg IV BD

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ. ERYTHROPOETIN 4000 IU once weekly

TAB. OROFER XT PO OD

Vitals monitoring

Temperature charting

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SHORT  CASE  

A 71 year old male , labourer 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

History: 

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 progressed 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 and bladder movements are regular

.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-

.Not significant

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 intercoastal indrawing

Palpation-

.All inspectory 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

P/A examination:

.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 upper lobe fibrosis

Investigations-

CBP-

CUE-

LFT-

2D echo-

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