50yr old M with c/o sob and cough since 15days
10/03/2023
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Name: K. Thanmai(intern)
Roll no: 76
A 50year old gentleman came to casuality with complaints of
Cough since 1month
Fever since 1month
Shortness of breath since 1week
HOPI:
Pt was apparently asymptomatic 1month back later developed fever which was high grade and continuous in nature, associated with chills and rigors. Relieved on taking medication
C/o cough associated with white colored sputum,non foul smelling,mucoid in consistency,non blood tinged since 1month
But gives h/o 1episode of blood tinged sputum yesterday
C/o sob initially on exertion since 1week
Also complained of chest pain which was diffuse,pricking type,mild pain, aggravated on coughing since 1week
H/o weight loss (2kgs in this month)
Decreased Appetite since 1month
PAST HISTORY:
H/o Pulmonary tuberculosis (clinicoradiological)
H/o usage of inhalers since 10years(he used to suffer from seasonal cough,sob since 10yrs)
N/K/C/O Htn,DM,asthma, epilepsy,CAD,CVA
PERSONAL HISTORY :
Occupation :Farmer
Appetite: decreased since 1week
diet non veg
bowel and bladder movements normal
FAMILY HISTORY:
Insignificant
GENERAL EXAMINATION :
patient is conscious cooperative coherent well oriented to time place person
No pallor, icterus, cyanosis, clubbing , lymphadenopathy, edema
Vitals :
Temperature : 102°F
PR: 110bpm
RR:20cpm
BP 100/60mmhg
spo2: 95% at room air
GRBS :102
SYSTEMIC EXAMINATION :
CVS: S1S2 heard, no cardiac murmurs heard
RS: NVBS heard, Dyspnoea present ,Crepts heard
P/A: Soft,non tender
Bowel sounds heard
CNS :
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- Both upper and lower limbs normal
Rt Lt
Power- UL: 5/5 5/5
LL. 5/5 5/5
Reflexes Right Left
Biceps ++ ++
Triceps. ++. ++
Supinator + +
Knee. ++. ++
Ankle ++. ++
INVESTIGATIONS:
Hb:12.2g%
TLC:8,400cells/cumm
PLATELET COUNT:2.79 laks/cumm
PCV:38
CUE:
SUGARS: NIL
ALBUMIN: NIL
UREA:32
SE.CRETAININE:0.9
SODIUM:135
CHLORIDE:97
POTASSIUM:3.1
IONISED CALCIUM:0.97
LFT:
TB:1.54
DB:0.26
ALP:98
TP:6.0
ALBUMIN;2.8
A/G RATIO:0.87
RBS:93
ESR:100
CRP:POSITIVE(1.2mg/dl)
ECG:(09/03/2023)
ECG(10/3/23)
CHEST X-RAY(PA VIEW)
USG ABDOMEN:
Raised echogenicity of B/L kidneys
USG CHEST:(10/3/23)
IMPRESSION:
B/l mild pleural effusion
B/l mild apical pleural thickening
Consolidatory changes in b/l lung fields predominantly upper zones
PROVISIONAL DIAGNOSIS:
K/C/O PULMONARY TB(CLINICO RADIOLOGICAL)
WITH ?ANTERIOR WALL MI
WITH RIGHT BUNDLE BRANCH BLOCK
TREATMENT GIVEN:
(10/3/2023)
1.ANTI TUBERCULAR DRUGS 2TABS/PO/OD
2.INJ.PAN 40MG IV/OD
3.INJ.ZOFER 4MG/IV/SOS
4.INJ.NEOMOL 2GM/IV/SOS(IF TEMP>101°F)
5.INJ.OPTINEORON 1AMP IN 500ML NS/IV/OD
6.TAB.ECOSPORIN AV 75MG PO/HS
7.TAB.PCM 650MG/PO/TID
(11/03/2023)
1)TAB.ISONIAZID 75MG 2TABS/DAY
TAB.RIFAMPICIN 150MG 2TABS/DAY
TAB.ETHAMBUTOL 275MG 2TABS/DAY
TAB.PYRAZINAMIDE 400MG 2TABS/DAY
2.INJ.PAN 40MG IV/OD
3.INJ.ZOFER 4MGIV/SOS
4.INJ.OPTINEURON 1AMP IN 500ML NS IV/OD
5.INJ.NEOMOL 1GM/IV/SOS(IF TEMP> 101°F)
6.TAB.ECOSPORIN 75MG PO/HIS
7.TAB.PYRIDOXINE 40MG/PO/OD
8.TAB.PCM 650MG PO/TID
9.SYP.ASCORYL-LS PO/TID
10. SYP POTKLOR 15ML PO/TID
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