General medicine case discussion

 G. Supriya reddy 42

67 year old male, sarpanch by occupation resident of nalgonda came with chief complaints of 

cough since 1month and 

breathlessness since 1month.

HISTORY OF PRESENT ILLNESS

Patient was apparently normal 1month back. Later he developed shortness of breath since 1 month. Increased on lying down, exertion, decreased on sitting position, taking rest. History of wheeze, cough since 1month with expectoration, mucoid, non foul smelling, No diurnal or postural variation, h/o decreased urine output since 1week.H/o pedal edema since 1week . Loss of appetite, no loss of weight. H/o chest pain, abdominal distension, Tendernrss, pain and fever. 

HISTORY OF PAST ILLNESS

H/o similar complaints  in past since 2years.

Not a known case of Hypertension, diabetes mellitus, CAD. 

No history of TB or covid 19

PERSONAL HISTORY

APPETITE-Normal

Mixed diet

BOWELS-Regular

MICTURITION-Decreased urine output since 1week

ADDICTIONS-Occasional alcoholic, beedi 40/day

FAMILY HISTORY

No family history

TREATMENT HISTORY

No treatment history

PHYSICAL EXAMINATION

A. GENERAL

VITALS

BP-110/80mmhg

PULSE RATE-90/min

SP02-86% at room air

GRBS-102mg%

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

BAE Present

Vesicular breathe sounds

Bilateral crypts

INVESTIGATIONS

FASTING BLOOD SUGAR-112mg/dl

LIVER FUNCTION TEST

TOTAL BILIRUBIN-0.87mg/dl

DIRECT BILLIRUBIN-0. 20mg/dl

SGOT-16IU/L

SGPT-10IU/L

ALKALINE PHOSPHATASE

TOTAL PROTEINS-6. 5gm/dl

ALBUMIN -3. 22gm/dl

A/G ratio-0. 98

RENAL FUNCTION TEST

UREA-83mg/dl

CREATININE-2. 6mg/dl

URIC ACID-10mg/dl

CALCIUM-8. 2mg/dl

PHOSPHORUS-5. 7mg/dl

SODIUM-143mEq/l

POTASSIUM-4mEq/l

CHLORIDE-101mEq/l

POST LUNCH BLOOD SUGAR

162mg/dl

ABG-

ULTRASOUND-

COLOUR DOPPLER 2D ECHO-

PROVISIONAL DIAGNOSIS

Acute exacerbation of COPD with type ll respiratory failure with severe PAH with corpulmonale. 

TREATMENT

1.Inhalation nasal prongs 2.4l/min

2.inj.Augmentin 1.2gm/Iv 

3.inj.Pan 40mg iv before food

4.T.sildenafil 20mg/Tid

5.Syp. Aristozyme-2tsp Tid

6.T. Dytor 5mg/OD

7.Chest physiotherapy

8.T. Shelcal

9.T. Vitamin D-60, 000Iu

10.T. Renosava-OD

11.T. Nodosis 500mg OD





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