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
Comments
Post a Comment