80 yr old male with right lung collapse
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 80 year old male patient was brought to casualty(i.e 4/10/2022)
Chief complaints:
Shortness of breath since 4days
Fever since 4days
Cough since 3days
Loose stools 2days
History of present illness:
Patient was apparently symptomatic 1 month back then he developed anuria for which he was admitted in a hospital for a day foleys was placed and medication was given for 10 days ,then patient developed shortness of breath four days back which was insidious in onset gradually progressed from grade 2 to grade 4 (mmrc),no postural variation ,no history of suggestive of paroxysmal nocturnal dyspnoea, chest pain ,associated with cold and cough ,cough was productive, sputum mucoid,whitish,copious and not blood tinged and has a history of fever which was intermittent ,on and off ,no diurnal variation and associated with loose stools and burning micturition ,loose stools since two days 3 to 4 episodes per day ,non-bulky not associated with pain abdomen ,non-bloodstained .
This developed after drinking beer(2bottles)
Past history:
No similar complaints in the past
Not a known case of DM,ASTHMA,HTN,EPILEPSY,TB
30 years back, when he developed a swelling on the right lower chest , pasaramandhu was used after which the patient is tilted to right side.
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 known 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 findings.
Trachea is deviated to right
Lung expansion is less on right side.
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 0.3I
NVESTIGATIONS
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
Comments
Post a Comment