80 yr old male Patient come with the chief complaints of

Sob 4 days 

Cough 3 days 

Fever 4 days 

Loose 2 days 

Burning micturation 2 days 

Patient was apparently symptomatic 1month back  then he developed loose tools and fever for which he was taken to hospital and was treated conservatively. Patient was symptomatically improved after 10 days for the treatment then last 4 days patient developed sob and insidious onset slowly progress to present state fever is intermittent on of associated with loose tools relieved on medications associated with burning micturation loose tools in students 3 to 4 episode for the not bloody watery non smelling and sticky

Cough since 3 days productive cough copious sputum which not bloody tinged  nonfrothy 

N/k/c/o DM tb cad htn asthma epilepy

H/0 surgery for hernia alone 7 years back 

Personal history :

Appetite normal 

Diet mixed 

Addiction smoking alcoholic 

Bowel and bladder irregular loose stools DECREASED urine output 

Family history : 

No significant family history






















Past history:


No similar complaints in the past


Not a know case of DM,ASTHMA,HTN,EPILEPSY,TB


H/O pasaramandu done 30 years back




Personal history:


Diet:mixed


Appetite:normal


Bowel and bladder movements:irregular (loose stools), decreased urine output since 1month


Addictions: alcohol consumption from past 30years (daily quarter) stopped 1 month back , last intake was 5 days back


          Smoking (Chutta) daily 4-5 , stopped 5 years back


No know allergies 




Family history:


No relevant family history










General Examination:


Patient was not C/C/C not oriented to time,place and person


Pallor -absent


Icterus-absent


Cyanosis-absent


Clubbing-absent


Lymphadenopathy-absent


Edema-absent




Vitals:


PR:87bpm


BP:140/70mm Hg


RR:35cpm


Spo2:94%


RBS: 228 mg/dl



















Systemic examination:


RS:


Inspection :


                                          R. L


Supraclavicular area :hollow. Normal


Infraclavicular area. :Crowding Normal


Position of trachea :prominent SCM on rigth side


Position of Apex beat :5 th ics


Chest : asymmetry


Increased AP diameter on left side




Palpation:


Confirmed inspiratory finding






Trachea deviated to rigth


Irregular chest movements 



Percussion:




Auscultation :

Decreased air entry on rigth side

Normal vesicular breath sounds 




CVS:


Apex beat at 5th ics at midclavicular line


 S1,S2 heard




Per abdomen: 


Scaphoid


Scar + rt side( h/o? hernia sx)


No Tenderness 

No organomegaly 


CNS:

Involuntary movements (? Fasiculations + at rt and lt proximal lowerlimb)

Tone : normal in all limbs

Reflexes: 

           Rt. Lt.

  B. +++ ++

  T. ++ +

  K. ++ ++

  A. ++ ++    

  P. Mute


   

Intially pulmonology consultation done : 

Suggested Bipap with peep 5 and fiO2 0.3


Investigations:



4/10/22:













5/10/22:




























6/10/22:

















7/10/22:










8/10/22:








Provisional diagnosis:

Altered sensorium (hypoactive) secondary to type 2 respiratory failure,?uremic encephalopathy Non oliguric aki with rt upper lobe fibrosis(?TB)


Treatment:(4/10/22)


1. IV fluids -NS,RL 

2.nebulization with milk and salbutamol

3. 25D with 10units HAI inj stat

4. Watch for hypoglycemia

5.inj lasix 40mg iv stat

6. 25D infusion /10ml/hr until 150ml /dl

7. Hourly GRBS monitoring

8. Monitor vitals hrly charting

9.strict i/o charting

10.syp. grillinctus 15ml/oral/BD



5/10/22:




Our patient was fighting with ventilator which has objective evidence of RR 56CPM. So we paralysed him and controlled his RR @ 24cpm.





O/E:

Pt was on mechanical ventilation

PR:78bpm

BP:110/80mmhg

CVS: S1,S2 heard

RS: decreased breath sounds in inframammary area rigth side

Left side NVBS

Crepts rt.axillary

P/a: soft nontender,scaphoid , non distended

CNS: no focal neurological deficits


Treatment:(5/10/22)

1.Iv fluids -75ml/hr ,ns rl

2.inj. monocef -1gm/iv/BD -8am 8pm

3.inj. midazolam -4ampules @5ml/hr

4.inj . Atracurium-2 ampules+45ml NS 

5. 25D infusion @15ml/hr Inc or dec to GRBS

6.Air bed

7. Frequent position changing

8.ryles tube milk 100ml, water 100ml

9. Nebulization budecort BD 12 hrly,asthalin

10.inj. pan 40mg iv OD

11.inj lasix 40mg iv BD

12.Tab. dolo 650mg sos(>100F)



6/10/22:


O/E:

Pt on mechanical ventilation

GCS-E1VTM1

Afebrile

PR:89bpm

Irregular rhythm

BP:120/80mmhg

GRBS:220mg/dl

CVS: S1 S2 heard

RS: decreased breath sounds in inframammary area rigth side

Left side NVBS

Crepts rt.axillary

P/a: soft nontender,scaphoid , non distended

CNS:

        R. L

B. +. +

T. +. +

K. -. +

A. +. +

P. Mute Mute


Treatment:(6/10/22)

1.iv fuilds @125ml/hr rl,ns

2.inj. monocef 1g/iv/bd

3.25D infusion @5ml/hr

4.inj. pan 40mg iv OD

5.inj. lasix 40mg iv bd

6.ryles tube milk 100ml, water 100ml

7.air bed

8. Frequent position changing 2hrly

9.neb budecort BD 12 hrly, asthalin 3hrly

10.tab dolo 650mg sos

11. Vitals monitor hrly

12.GRBS charting

13.strict i/o charting

14. Inform SOS


Plan for hemodialysis (rt femoral line )


 Central line (rt femoral vein)



7/10/22:






8/10/22:



O: Patient on Mechanical Ventilator 

Mode: CPAP VC

RR total: 40

FiO2 : 30

PEEP: 7

Temp-99.5°F

BP-120/70 MMHG

PR-80 BPM

RR-24 CPM

CVS-S1S2+

RS: BAE+ 

Crepts + Left infra axillary added sounds @ left infclavicular, right mammary 

P?/A : soft, non- tender 

SPO2 - 98% 

GRBS: 138mg/dl

GCS: E1VtM4




A: 

Altered Sensorium ( hypoactive) secondary to T-II respiratory failure? 

Uremic Encephalopathy

Non Oliguric AKI? AIN? ATN with Right Upper Lobe Fibrosis 

Post Hemodialysis (1 session on 06/10/22 ) 


P:

1. IVF NS and RL @ 50mL /hr 

2. INJ. MONOCEF 1g/ IV/BD 

3. INJ. LASIX 80mg /IV /BD 

4. Ryles feed - milk (100 mL+ protein powder) 4th hourly 

   water - 100mL 6th hourly 

5. TAB. AZITHROMYCIN 500mg /RT/OD 

6. TAB. DOLO 650mg/RT/SOS if temp. more than 101F 

7. Air bed 

8. Nebulisation 

  - Budecort /BD/12th hourly 

  - Asthalin / TID/ 8th hourly 

9. Frequent position change 2nd hourly 

10. Monitor vitals BP, Temp, PR, RR, SpO2 hourly 

11. GRBS charting 2nd hourly 

12. Strict I/O charting 

13. Inform SOS










       



 






          




Comments

Popular posts from this blog

20 yr girl with b/l pedal edema

19 year old female with fever since 1week

INTERN ONLINE ASSESSMENT- GENERAL MEDICINE