Unit II admission on 16/02/2021
DR. AMULYA ( INTERN)
DR. YAMINI ( INTERN)
DR. SURYA PRADEEP ( INTERN)
DR. ASHA KIRAN ( INTERN)
DR. JAYANTH ( INTERN)
DR. VAMSHI ( INTERN)
DR. ISMAIL (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR)
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI
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.
A 56 year old male who is a farmer came to hospital with complaints of
1.) SOB on walking for short distance since 1 month.
2.) Dry cough since 10 days which is on and off
Patient was apparently asymptomatic 3 years back when he had history of pulmonary kochs, used treatment for 8 months , followed by
1.SOB on doing routine work since 2 years. Not associated with orthopnea, PND and pedal edema.
Aggravated since 1 month progressed to walking for a short distance , not at rest.
2. Dry cough intermittently increased on exposure to cold . No postural variation, no diurnal variations, no seasonal variations.
No history of chest pain, palpitations , wheeze.
History of past illness :- K/C/O pulmonary kochs 3 years back. Used ATT for 8 months.
Not a k/c/o DM2, HTN.
Used T. Uroflow intermittently for ? Prostatomegaly since 2 years.
Treatment history :- no documentation, angiography done in 2017.
Used ATT for 8 months, 3 years back
Personal history :-
He was an agricultural worker, stopped going to work since 2 years because of shortness of breath.
Bowel movements - constipated since 10 days.
Micturation - dribbling of urine since 3 months.
Addictions - Regular consumption of alcohol ( 90 ml whiskey for 20 years, stopped 3 years back )
Smoked 1 pack of beedi per day for since 35 years , stopped since 3 years.
EXAMINATION:-
patient is conscious and coherent.
BP - 130/90 mmHg ; Temperature - afebrile ; PR - 88bpm ; RR - 26 cpm ; SPO2 - 82% at RA
95% on 6L O2.
Mild dehydration present.
No signs of pallor, icterus, cyanosis, clubbing of fingers, pedal edema.
CVS :- S1 S2 heard , no thrills , no murmurs.
RS :- Dyspnea grade 3. Wheeze present.
a) Inspection -
Upper respiratory tract - Normal
Lower respiratory tract -
Bilateral symmetrical , elliptical shaped
Not prominent sternocleidomastoid muscles . Abdomino-thoracic type of breathing . Trachea appears central.
No drooping of shoulders , supraclavicular hollowing on left and fullness on right. No infra clavicular flattening. Respiratory movements appear equal on both sides.
b ) Palpation -
Position of trachea central .
Circumference of chest - 82 cm.
Antero- posterior measurement - 23 cm
Respiratory movements equal on both sides in all lobes. Vocal fremitus normal.
c) Percussion
Normal
d) Auscultation
Bilateral airway entry present
Vocal resonance decreased on left ISA
Breath sounds tubular in Lt infrascapular
area. ?Rhonchi in right ISA. Wheeze present.
P/A :- scaphoid shape, no tenderness, palpable mass, free fluid , bruits. Hernial orifices normal.
CNS :- Concious with normal speech .
No signs of meningeal irritation.
No motor, sensory and cranial nerve deficits.
PROVISIONAL DIAGNOSIS
Right sided HF with AKI (? Post renal) on CKD with k/c/o old pulmonary kochs with denovo HTN.
TREATMENT
1.) Inj. Lasix 40 mg IV BD
2.) T. Amlong 5mg PO OD
3.) Fluid restriction less than 1.5 L per day
4.) Salt restriction less than 2gm per day
5.) Strict I/O monitoring
6.) BP /PR monitoring 4th hourly.
7.) Neb with 2 respules Budecort 12th hourly.
8.) Oxygenation to maintain SPO2 above 90%
9.) T. Tamsulosin 0.1 mg H/S for 30 days
