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65 YEAR OLD MALE PATIENT WITH FEVER ,COUGH, SHORTNESS OF BREATH

 This is an 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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 on the comment box is welcome.

Here is a case i have seen:

65 year old man presented with the complaints of 

Reduced urine output since 1 year

Dyspnea since 4 months  

Fever since 1 month

Cough since 1 month 

Numbness in bilateral lower limbs since 20 days

Bilateral lower limb swelling since 20 days 

He has been working as a farmer at Borrayapalem at Nalgonda district. He has 4 children, 3 daughters and one son, the attendant who got the patient to the hospital. He has been an occasional alcoholic since 25 years and was a smoker for around 30 years, used to smoke around 7-10 beedis per day. 

He was apparently alright one year back after which he started to notice reduced urine output. He would often  feel dyspneic after walking for a short duration since several months. Since 1 month he has been experiencing low grade fever on and off along with cough without expectoration. He also says he has been even more dyspneic over the last one month. He says he has been feeling numbness in both his lower limbs.Bilateral swelling of both his lower limbs also developed gradually extending to his knees. He also tells that there has been slippage of footwear since 1 week. He finally visited a local hospital, where in he was diagnosed with CKD with Heart failure and he received Spironolactone 50mg plus torsemide 20mg.  He was even diagnosed to be a hypertensive and diabetic. 


On presentation to us, 

He was thin built

With pallor and bilateral pedal edema 

His PR was 68bpm

BP was 150/100mmhg

A febrile 

CVS - 

On inspection - Barrel shaped chest was present


                     BARELL SHAPED CHEST

Locomotor brachialis +


His Apex beat was visible 



Dancing carotids 


               Dancing carotids +

               no raised jvp -


On palpation - apex beat in 6th ics 2cms away from the MCL , heaving type 

On auscultation-  muffled S1,S2 +

 

Respiratory examination - 

Supraclavicular indrawing +

Intercostal indrawing +

On percussion - 

Dullness + in Bilateral IAA, ISA 

Vocal resonance reduced in right ICA,IMA,IAA,ISA

Inspiratory crepts + Bilateral IMA,IAA,ISA

decreased breath sounds+ in ISA


INVESTIGATION:

ecg:


x -ray:



heamogram


CUE


RFT



lipid profile


2D echo:





HRCT THORAX












Juxtphrenic sign - small triangular opacity near done of diaphragm due to stretching of inferior accessory fissure or inferior pulmonary ligament
 
Tram track and signet ring appearance present


culture and sensitivity


PLBS


TREATMENT::

DAY 1:

1) neb with duolin 6th hrly


                   budicort 12 th hrly

                   mucomyst 6th hrly

2) inj augmentin 1.2gm iv bd

3) inj lasix 40 mg iv bd (@8am and 4pm)

4)inu pan 40 mg iv bd

5)inj zofer 4 mg iv sos

6) inj neomal 100 ml iv

7)tab.azithromycin 500 mg po od

8)tab dolo 650mg po sos

9) syp.ascoril 10 ml po tid

10)tab amlong 5 mg od

11)tab. nicardia 10 mg bd

12) tab buscopan po od

13)syp.lactulose 15 ml po hs.

DAY 2::

clo pain Abdomen 
       low grade fever 
       cough 
      constipation since 3 days 

1) neb with duolin 6th hrly

                   budicort 12 th hrly

                   mucomyst 6th hrly

2) inj augmentin 1.2gm iv bd

3) inj lasix 40 mg iv bd (@8am and 4pm)

4)inu pan 40 mg iv bd

5)inj zofer 4 mg iv sos

6) inj neomal 100 ml iv

7)tab.azithromycin 500 mg po od

8)tab dolo 650mg po sos

9) syp.ascoril 10 ml po tid

10)tab amlong 5 mg od

11) tab buscopan po od

12)syp.lactulose 15 ml po hs.

DAY 3:

clo  shortness of breath 
       fever 
      cough 
      fine tremors

1) neb with duolin 6th hrly

                   budicort 12 th hrly

                   mucomyst 6th hrly

2)inj augmentin 1.2gm iv bd

3) inj lasix 40 mg iv bd (@8am and 4pm)

4)inu pan 40 mg iv bd

5)inj zofer 4 mg iv sos

6) inj neomal 100 ml iv

7)tab.azithromycin 500 mg po od

8)tab dolo 650mg po sos

9) syp.ascoril 10 ml po tid

10)tab amlong 5 mg od

11) tab buscopan po od

12)syp.lactulose 15 ml po hs.

13)Tab .Ecosprine AV 75mg HS

14)Tab.Met XL 25mg po


DAY 4 :

No fresh complains 
patient symptomaticaly better

1) neb with duolin 6th hrly

                   budicort 12 th hrly

                   mucomyst 6th hrly

2)inj augmentin 1.2gm iv bd

3) inj lasix 40 mg iv bd (@8am and 4pm)

4)inu pan 40 mg iv bd

5)inj zofer 4 mg iv sos

6) inj neomal 100 ml iv 

7)tab.azithromycin 500 mg po od

8)tab dolo 650mg po sos

9) syp.ascoril 10 ml po tid

10)tab amlong 5 mg od

11) tab buscopan po od

12)syp.lactulose 15 ml po hs.

13)Tab .Ecosprine AV 75mg HS

14)Tab.Met XL 25mg po 



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