A 65Y/M with complaints of SOB

This is a online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patients problems through series of inputs from available global community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This E log book also reflects my patient centered online learning portfolio and your valuable inputs in comment box is welcome.
 
A 65 years old Man Who is Resident of Narketpally who was Alcohol ( Sara ) Seller & Shepherd by Occupation Came with C/O 
Fever Since 3 Days 
HOPI : 
At 10 years of Age Patient Was apparently Asymptomatic Till 10 years of Age & Once day He Climbed & Fell Down While Cutting Tree leaves for feeding Their Goats & Had a Fracture of Lt.Forearm & Went to Nalgonda District Hospital where Cast was applied & After 20 days He developed infection & a part of Bone was Protruded out & That part of Bone was excised.
10 years Back : 
After Having a alcohol Binge Patient Developed Generalized Weakness & Got admitted in Our Hospital for 4-5 days
7 years Back : 
Patient Developed Giddiness & Went hospital & was diagnosed with DM2 & HTN for which he was Prescribed Tab.METFORMIN 500mg
Tab.AMLONG 5mg 
6 Months Back : 
Patient Developed Both Lower Limb Swelling which was Pitting type & Upto Knees & Diagnosed to have Left Upper Ureter Calculi & CKD For which he was planned for Surgery But Couldn't not be done as patient wasn't fit for Surgery & Was Managed Conservatively with Tab.NODOSIS 500mg BD.He Has Dry Cough Occasionally Since 6 Months & 3 Days Back Then Had Fever with Chills Which was High Grade Continuous & Relieved on Taking Medications.
Personal History: 
Patient Used to Sell Alcohol ( Sara) for almost 20 years & Used to Drink Daily the Same thing he used to Sell. Then he used to Drink 90-180ml of Whisky Till 6 Months Back & From Six Months He Drinks Occasionally During Festivals.


PERSONAL HISTORY:
Appetite : Decreased
Diet : Mixed
Bowel and bladder : Regular
Sleep : Adequate

Pt is conscious coherent and cooperative well oriented to time place and person

Pallor : Present
Cyanosis : Absent
Clubbing : Absent
Lymphadenopathy : Absent
Pedal Edema: pitting type extending upto knee joint 

Systemic examination: 

RESPIRATORY SYSTEM:
Inspection:
Shape- elliptical 
B/L symmetrical,
Decreased movements on right side mammary region, infra scapular region  .
Engorged veins on the left side 
No scars, sinuses, pulsations 

Palpation:
Inspectory findings are confirmed 
Trachea - central
AP diameter 16 cm
Transverse diameter 23 cm
Expansion of chest is symmetrical. 
Vocal fremitus - normal

Percussion: 
Dull note on right mammary, interscapular infra axillary,  infrascapular

Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard. Decreased breath sounds on right mammary, interscapular infra axillary, infrascapular

CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest is elliptical.
No raised JVP
No visible pulsations, scars , sinuses , engorged veins.

Palpitation:
Apex beat - felt at left 5th intercostal space
No thrills and parasternal heaves

Auscultation :
S1 and S2 heard.

PER ABDOMEN:
Inspection :
Umbilicus is central and inverted
All quadrants are moving equally with respiration 
No scars , sinuses , engorged veins, visible pulsations 
Hernial orifices are free.

Palpitation :
Abdomen is soft and non tender .
No organomegaly.

Percussion :
Tympanic note heard over the abdomen.

Auscultation:
Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:on the day of presentation 

Conscious,coherent and cooperative 
Speech- normal
No signs of meningeal irritation. 
Cranial nerves- intact
Sensory system- normal 

Motor system:
Tone- normal
Power- bilaterally 5/5
Reflexes Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++

27/1/2023 













On admission  pleural tap was done and 300 ml of pleural fluid was drained  


22/1/23






16/07/2022



Serial ABG trends

Pleural fluid cytolgy












SPUTUM AND PLEURAL FLUID CBNAAT WAS NEGATIVE

S - 
NO FEVER SPIKES 
C/O BREATHLESSNESS REDUCED

O-
PULSE -  76 bpm 
BP - 130/80 mmhg 
TEMP - 99 F  
CVS - S1 , S2 +
RS - BAE + , NVBS, DECREASED BREATH SOUNDS IN RIGHT INFRA AXILLARY AREA, INSPIRATORY CREPTS IN B/L ICA
PA - SOFT , NON TENDER
CNS - NAD

INPUT 1100 ML
OUTPUT 1050ML

CREAT- 4.4 (D1)- 4.5 - 5.3 - 4.0 - 4.3(D5)

A

RIGHT PLEURAL EFFUSION (SECONDARY TO TB) STAGE 5 CKD WITH LEFT HYDROURETERONEPHROSIS (10 MM CALCULUS AT LOWER POLE ) WITH ANEMIA OF CHRONIC DISEASE WITH DM -2 AND HTN (SINCE 4 YRS)

P

INJ AMOXYCLAV 1.2 GM IV/BD - D6

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

Image
  INTERNSHIP ASSESSMENT: Posted in department of GENERAL MEDICINE from 12/12/22 to 11/2/23. PSYCHIATRY POSTING:(from 12/12/22 to 26/12/22) Learned about importance of history taking and how to reach to provisional diagnosis through history taking. Seen different patient in op: 1.Schizophrenia 2.Alcohol Dependence Syndrome 3.Tobbaco Dependence Syndrome 4.OCD 5.Panic attack 6.Psychosis Learnt medications given to the patients and their side effects. Learnt about audit score - a parameter used in evaluating alcohol dependence. UNIT DUTIES: 27/12/22 to 26/1/23 In OP: Took brief history of patients, done systemic examination. Ordered necessary investigations according to the symptoms. Learnt to pescribe medications according to symptoms of the patient. In Unit: Drawn venous blood samples,collected reports of samples sent. Updated fever chart everyday.Updated reports in unit group and investigations charts. Got ECG,2D echo and xray done for the patients admitted under the unit. Initiated and
Read more

A 22yr old primigravida...

Image
CASE REPORT :: A 22 year old primigravida with gestational age of 10 weeks who is housewife who is a resident of munugodu was brought with  CHIEF COMPLAINTS : Muscle spasms involving both upper ,  lower limb and neck since yesterday evening.  PAST HISTORY :: Not a known case of DM, HTN, Tuberculosis , asthma. No history of blood transfusion and major surgeries. PERSONAL HISTORY : Appetite :normal Diet : mixed  Sleep : adequate  Bowel and bladder : regular  No addictions. No known drug and food allergies. FAMILY HISTORY : No history of epilepsy in the family. GENERAL EXAMINATION : Patient is conscious coherent cooperative and well oriented to time place and person. Consent of the patient and attenders was taken and examined in a well lighted room. Patient is moderately built and nourished.  Pallor -  Present   Icterus - absent  Cyanosis - absent  Clubbing - absent Lymphadenopathy - absent Edema - absent VITALS  : Temperature : afebrile  Pulse rate - 78 beats per minute , normal rhythm a
Read more