65 yr old male with right LL consolidation

 A 65 yr old male came to hospital with c/o

- breathlessness since 4 days. 

- fever since 4 days. 

- cough since 3 days.

HOPI -

Patient was apparently asymptomatic 4 days back, then he developed breathlessness which is insidious in onset, not associated with wheeze, increased on execution, orthopnea present, relieved with rest.

HR also c/o fever since 4 days, not associated with chills, evening rise of temperature present

He also c/o cough since 3 days, non - expectorant, increases on exposure to cold air. 

C/o loss of weight, loss of appetite present, biomass exposure +. 

No c/o chest pain, chest tightness, hemoptysis, palpitations, decreased urine output. 

Past History :

N/k/c/o HTN, DM, epilepsy

Past h/o similar c/o SOB  in winter season and usage of inhaler in the season occasionally (SOS).

No past h/o TB, covid 19

Personal history :

Loss of appetite +

Sleep - inadequate.

Occupation - farmer

Bowel and bladder g revular

Alcohol - regular 90ml/day daily

Smoking - beedis 2-3/day for 25 yrs, stopped 4yrs back. 

Family history g not significant 

General examination :

Patient is c/c/c tin built and moderately nourished. 

No pallor, icterus, cyanosis, clubbing, Lymphedenopathy or oedema. 

Temp - 99. 2 'F

PR - 98bpm

BP - 130/80 mmhg. 

Sp02 - 93%.

GRBS - 78mg%. 

CVS - S1 S2 +, no murmurs

RESPIRATORY SYSTEM

 - dyspnoea +, Trachea - central, NVBS

Crepts present in Rt SSA, ISA, infra SA, I A, left infra SA. 

Inspection :shape of chest - elliptical 

Trachea - central

Expansion of chest equal on both sides

RR G 32 cpm

No usage of accessory muscles of resp

No dropping of shoulder

No crowding of ribs

No wasting of muscles

Spinoscapular distance equal on both sides

Palpation :

All inspectory findings confirmed

No local rise of temp

No tenderneaa

Apex beat in left 5th ICS medial to mid clavicular line

Percussion:

Direst - resonant

Indirect - resonant. 

Auscultation :

Crepts + Rt SSA, USA, infra SA, ICA, left infra SA

P/A: soft, Non tender

CNS - NAD

Investigations on 15/5 22

Hb- 9.4gm%

TLC - 13,200

N/L/E/M - 67/27/1/5

PLT - 1.5 lakh

BT - 2min, CT - 5min

BGT - B +ve

Serology HBsAg, HIV - negative

HCV - positive

RFT : 

urea-101, 

Creatinine - 1.7

Uric acid - 8.8

Ca- 10, Ph - 4.7, Na- 141, K- 4.2, Cl- 99

LFT :

TB-0.67, DB - 0.2,

SGOT - 39, SGPT - 35, ALP - 119

TP - 5.5, Alb - 2.5, A/G - 0.84.

ABG-

ECG-

chest x ray - 


USG-

2D ECHO-



Diagnosis-Right LL consolidation 2` to? CAP,? TB with CKD 

Treatment - 

1.O2 with nasal prongs @2-3 lit/min 

2. IVF 1unit NS  @ 50ml/hr

3.Inj AUGMENTIN 1.2 gm IV /TID

4.TAB AZEE 500mg PO/OD

5.Neb with Duolin - 6th hrly, mocomist - 2nd hrly

6. Inj PAN 40mg OD BBF

7. TAB MUCINAC Ab TID

8.SYP ASCORIL 2tsp TID

9.TAB PCM 650mg BD

10. INJ NEOMOL 100ml IV /STAT 




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