80 yr old male with right lung collapse
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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
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