Case 7. 66 M with SOB,Fever,cough

DOA 17/10/2023

EXPIRED ON 19/10/2023

Diagnosis

MASS IN THE RIGHT LUNG WITH DIABETIC KETOSIS WITH ? PNEUMONIA OF RIGHT LUNG

K/C/O CAD 3 YEARS

WITH K/C/O OLD TB WITH K/C/O HTN AND DM II

Case History and Clinical Findings

C/O SOB SINCE 7 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO THEN HE DEVELOPED SOB OF

INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED

SINCE PAST 2 DAYS

COUGH + WITH EXPECTORATION,BLOOD TINGED +

FEVER + SINCE 7 DAYS ,LOW GRADE NOT WITH CHILLS AND RIGOR,COLD-

SORE THROAT -, ABDOMINAL PAIN -,VOMITING -,LOOSE STOOLS -

N/KC/O CVA,TB,EPILEPSY

K/C/O CAD since 3 YEARS

K/C/O TB SINCE 7 YEARS AGO USED MEDICATION

K/C/O HTN AND DM II SINCE 2 YEARS ON MEDICATION

PERSONAL HISTORY

APETITE-DECREASED

SLEEP-ADEQUATE

BOWEL AND BLADDER- REGULAR

NO ALLERGIES

CHRONIC SMOKER

GENERAL EXAMINATION

PATIENT IS CONSIOUS ,COHERENT,COOPERATIVE

NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

VTALS

PR-108 BPM

BP- 120/60 MMHG

RR-22 CPM

TEMP AFEBRILE

SYSTEMIC EXAMINATION :

CVS : S1 S2 HEARD , NO MURMURS

RS : BAE +,RHONCI ?

PER ABDOMEN : SOFT , NON TENDER , NO ORGANOMEGALY

CNS : HGHER MOTOR FUNCTIONS PRESENT , NO FND

PULMONOLOGY REFFERAL DONE I/V/O BLOOD TINGED SPUTUM AND PREVIOUS TB

ADVISED TRUNAAT,HRCT CHEST

PULMONOLOGY REVIEW REFERAL WAS TAKEN I/V/O MASS IN RIGHT LUNG ON HRCT

CHEST AND WAS ADVICSED FOR BIOPSY

FBS-389 mg/dl

PLBS -447 mg/dl

Hba1C- 9%

RFT

UREA 44mg/dl

CREATININE -1.1 mg/dl

Sodium-136 meq/dl

potassium-3.7 meq/dl

Chloride-99 meq/dl

Treatment Given(Enter only Generic Name)

NEB WITH BUDECORT 4TH HOURLY,IPRAVENT 6TH HOURLY

INTERMITTENT CPAP TO MAINTAIN SPO2 >95

IV FLUIDS 2. NS @ 75 ML/HR

INJ HAI ACC TO GRBS (SC/TID)

INJ PIPTAZ 4.5GM IV/TID

INJ NEOMOL 1GM/IV/SOS

SYP ALKASTONE PO/SOS

SYP GRILLINCTUS PO/TID

TAB ETHAMSYLATE 250MG PO/BD

INJ VIT K 10 MG IV

PATIENT EXPIRED IN OUTSIDE HOSPITAL