70 year old male came with the chief complaints of chest pain ,cough,sob

 70 year old male came with the chief complaints of chest pain ,cough,sob since 8-10 days

Fever since 1 week


Hopi-

Patient was apparently asymptomatic 8 days back then he developed cough- Dey,insidious in onset and gradually progressive,diurnal variations present more during night. No seasonal variations. No aggravating or relieving factors.

Chest pain left sided non radiating not associated with excessive sweating, palpitations,pedal edema,giddiness

Sob since 8 days insidious in onset and gradually progressive,progressed from grade 1 to grade 3 .

No orthopnea,no PND

No seasonal variation,no diurnal variation.

Fever since 1 week ,high grade associated with chills and rigors,

Evening rise of temperature present, loss of weight present, loss of appetite present

No h/o vomiting,losing stools,pain abdomen.


Past h/o- 

K/c/o HTN since 2 years

K/c/o DM since 6 months

Not a k/c/oNot a k/c/o asthma , tb , epilepsy and thyroid disorders 


Surgical history - ?patient underwent exploratory laparotomy for intestinal perforation


Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions- alcohol- regular

Smoking - smoker for 30 years,

Stopped 10 years ago


Family h/o - not significant


On general examination - 

patient is conscious,coherent and cooperative 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema


Vitals- 

Temp - 96.8 F

PR- 96 bpm

Bp- 110/70 mmhg

RR -26 cpm

Spo2-97%

Grbs-334 mg/dl

Systemic examination -

Cvs- S1 S2 present

RS - BAE present, NVBS

P/A- soft, non tender

CNS- NAD 

Reflexes-

                     Right.        Left 

Biceps.         2+.               2+

Triceps.        1+.               1+

Supinator.    1+.               1+

Knee.           .  2+.              2+

Ankle.            1+.               1+


Provisional diagnosis -

Left lung lower lobe cavitation secondary to ? TB with type 2 DM and HTN with AKI 

Investigations -


















Chest xray PA view-








29/03/23-

DOA- 28/03/23

70 year old male came with the chief complaints of chest pain ,cough,sob since 8-10 days

Fever since 1 week

S-

C/o cough, sob

Stools passed 4 times watery

1 fever spike at 4 am 


O-

O/E

patient is conscious,coherent and cooperative 


Vitals- 

Temp - 96.4F

PR- 92bpm

Bp- 100/60 mmhg

RR -24cpm

Spo2-94% on RA

Grbs-343mg/dl


Systemic examination -

Cvs- S1 S2 present

RS - BAE present, NVBS, left ma, iaa, isa crepts present 

P/A- soft, non tender

CNS- NAD 

Reflexes-

                     Right.           Left 


Biceps.          2+               2+

Triceps.         1+.               1+

Supinator.     1+.              1+

Knee. .             2+.             2+

Ankle.             1+.             1+



A-

Left lung lower lobe cavitation secondary to ? TB with type 2 DM and HTN with AKI 


P- 


Treatment -

IVF - NS  100 ml/hr

Inj. Piptaz 2.25 mg iv /tid

Inj. Pan 40 mg iv od

Inj. Hai s/c tid / premeal according to grbs

Tab. Dolo 650 mg p/o sos

Tab. Atenolol 25 mg po od

Tab. Sporolac -ds po/ tid

Grbs-  7 point profile 

Vitals monitoring 4 th hourly

Strictly I/o monitoring 


30/03/23-

DOA- 28/03/23

70 year old male came with the chief complaints of chest pain ,cough,sob since 8-10 days

Fever since 1 week

S-

C/o cough

C/o loose Stools passed 5 episodes watery

1 fever spike at 8 am 


O-

O/E

patient is conscious,coherent and cooperative 


Vitals- 

Temp - 102.7F

PR- 86bpm

Bp- 100/60 mmhg

RR -17cpm

Spo2- 95% on RA

Grbs-225mg/dl

Input- 1650ml

Output- 1750ml

Systemic examination -

Cvs- S1 S2 present, no murmurs

RS - BAE present, NVBS, left isa,iaa, ima crepts present 

P/A- soft, non tender

CNS- NAD 

Reflexes-

                     Right.           Left 


Biceps.          2+               2+

Triceps.         1+.               1+

Supinator.     1+.              1+

Knee. .             2+.             2+

Ankle.             1+.             1+


Investigations -

Hb- 7.8

Tlc- 11700

Neut- 90

Lym- 05

Pcv- 25.1

Rbc- 2.89

Plt- 1.96

PT- 19sec

INR - 1.3

Aptt- 38 sec

A-

Left lung lower lobe cavitation secondary to ? TB with AKI ( PRE RENAL) with HTN since 2 years with type 2 DM since 6 months


P- 


Treatment -

IVF - NS  100 ml/hr

Inj. Piptaz 2.25 mg iv /tid

Inj. Pan 40 mg iv od

Inj. Hai s/c tid / premeal according to grbs

Inj. Zofer 4 mg iv tid

Syp. Ascoryl -ls po/tid

Tab. Dolo 650 mg p/o tid

Tab. Atenolol 25 mg po od

Tab. Sporolac -ds  2 tab po/ tid

Grbs-  7 point profile 

Vitals monitoring 4 th hourly

Strictly I/o monitoring 


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