65M with bronchiectasis
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His case summary:
Age/Gender : 68 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 17/11/2024 08:57 AM
Diagnosis
COMMUNITY ACQUIRED PNEUMONIA BRONCHIECTASIS OF L UL SECONDARY TO OLD PTB
Case History and Clinical Findings
CHEIF COMPLAINS ;
C/O FEVER , COUGH WITH SPUTUM ,SHORTNESS OF BREATH SINCE 1 MONTH. HISTORY OF PRESENTING ILLNESS ;
THE PATIENT WAS APPARENTLY ALRIGHT 1 MONTH AGO AFTER WHICH HE DEVOLOPED FEVER INTERMITTENT IN NATURE ASSOCIATED WITH CHILLS AND RIGORS MORE IN EVENING AND RELIVED ON TAKING MEDICATION .C/O COUGH WITH SPUTUM WHITISH IN COLOUR ,CUPIOUS IN AMOUNT ,NON BLOOD TINGED ,NO DIURNAL VARIATION .C/O SHORTNESS OF BREATH SINCE 1 MONTH.INSIDIOUS IN ONSET GRADULLAY PROGRESSIVE FROM GRADE 1 TO GRADE 2 .
NO C/O ORTHOPNEA ,PND NO C/O CHESTPAIN ,PALPITATION PAIN ABDOMEN ,NAUSEA VOMITING .NO C/O WEIGHT LOSS AND LOSS OF APPETITEN.
H/O SIMILAR COMPLAINS IN THE PAST PAST HISTORY;
K/C/O PULMONARY TB 10 YR AGO AND USED ATT FOR 1 MONTH N/K/C/O HTN,DM,CAD,CVA,ASTHMA ,EPILEPSY,.
GENERAL EXAMINATION
NO PALLOR ,ICTERUS, CYANOSIS, CLUBBING ,LYMPHADENOPATHY, OEDEMA,. TEMP; 98.9F
PR; 72 BPM RR ; 30 CPM
BP ;110 /70 MM HG GRBS ;110
CVS ; S1S2 HEARD
RS BAE PRESENT ,BRONCHIAL SOUNDS PRESENT IN LE,MA B/L WHEEZE PRESENT
CREPTS PRESENT IN LT LAA, MA
COURSE OF HOSPITAL PATIENT HAS PRESENTED TO OPD WITH COMPALINS OF FEVER
,COUGH WITH SPUTUM,SHORTNESS OF BREATHSINCE 1 MONTH.ON EXAMINATION WAS FOUND FEVER SPIKES AND COUH WITH SPUTM .PATIENT WAS TREATED CONSERVATIVELY WITH ANTIBIOTICS, NEBULISATION,IV FLUIDS ,ANALGESICS,.PULOMONOLOGY OPINON WAS DONE AND GAVE MEDICATION .
HRCT CHEST WAS DONE AND REPTED AS CHRONIC ATELECTASIS OF LUNG UPPER LOBE WITH FIBROSIS BRONCHIECTASIS AND THIN WALLED CAVITY SEQUALE OF CHRONIC INFECTION .PARA SEPTAL EMPHYSEMA IN RIGHT APEX ,CENTRILOBULAR EMPHYSEMA IN B/L LUNG UPPER LOBE .
Investigation
LIVER FUNCTION TEST (LFT) 17-11-2024 09:08:AMTotal Bilurubin 0.90 mg/dl Direct Bilurubin 0.18 mg/dl SGOT(AST) 22 IU/L SGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 140 IU/LTOTAL PROTEINS 6.0 gm/dl ALBUMIN 3.4 gm/dl A/G RATIO 1.33
RFT 17-11-2024 09:08:AMUREA 24 mg/dl CREATININE 0.9 mg/dl URIC ACID 3.6 mmol/L CALCIUM
9.9 mg/dl PHOSPHOROUS 4.1 mg/dlSODIUM 138 mmol/L POTASSIUM 4.8 mmol/L.CHLORIDE 97 mmol/L ABG 17-11-2024 04:36:PMPH 7.34PCO2 49.7PO2 89.8HCO3 26.6St.HCO3 25.1BEB 0.8BEecf 1.5TCO2 53.9O2 Sat 96.4O2 Count 17.4
SERUM ELECTROLYTES (Na, K, C l) 17-11-2024 11:28:PMSODIUM 140 mmol/L POTASSIUM 4.3
mmol/LCHLORIDE 102 mmol/L
HAEMOGLOBIN 15.8 gm/dl TOTAL COUNT 10,400 cells/cummNEUTROPHILS 63 %
LYMPHOCYTES 30 % EOSINOPHILS 01 % MONOCYTES 06 % BASOPHILS 00 % PCV 46.8 vol
%M C V 88.1 fl M C H 29.8 pg M C H C 33.8 % RDW-CV 13.9 % RDW-SD 45.2 fl RBC COUNT 5.31
millions/cumm PLATELET COUNT 1.50 lakhs/cu.mm Treatment Given(Enter only Generic Name) T.PCM 650 MG PO/SOS
T.FLUCONOZOLE 150 MG PO/OD SYP .ASCORYL 10ML PO/TID T.PULMOCLEAR PO/BD
NEB WITH DUOLIN , IPRAVENT 8 TH HOURLY , BUDECORT 12 HOURLY
Advice at Discharge T.AUGUMENTIN625 MG PO/TID X 4 DAYS T.AZITHROMYCIN 5OOMG X 2DAYS
T.FLUCONOZOLE 150 MG PO/OD X 5 DAYS SYP .ASCORYL 10ML PO/TID X 5 DAYS T.PULMOCLEAR PO/BD X 15 DAYS
ROTAHALER FORACORT CAPS 200MG 2 PUFF TWICE DAILY
Follow Up
REVEW TO GM OPD AFTER 2 WEEKS /SOS.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date: 20/11/24 Ward:RICU
Unit:I
Investigations
Name Value Range Name Value Range
LIVER FUNCTION TEST (LFT) 17-11-2024 09:08:AM RFT 17-11-2024 09:08:AM
Total Bilurubin 0.90 mg/dl 1-0 mg/dl UREA 24 mg/dl 50-17 mg/dl
Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl CREATININE 0.9 mg/dl 1.3-0.8 mg/dl
SGOT(AST) 22 IU/L 35-0 IU/L URIC ACID 3.6 mmol/L 7.2-3.5 mmol/L
SGPT(ALT) 10 IU/L 45-0 IU/L CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl
ALKALINE 140 IU/L 119-56 IU/L PHOSPHATASE PHOSPHOROUS 4.1 mg/dl
SODIUM 138 mmol/L 4.5-2.5 mg/dl
145-136 mmol/L
TOTAL PROTEINS 6.0 gm/dl 8.3-6.4 gm/dl POTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.
ALBUMIN 3.4 gm/dl 4.6-3.2 gm/dl CHLORIDE 97 mmol/L 98-107 mmol/L
A/G RATIO 1.33
ABG 17-11-2024 04:36:PM SERUM ELECTROLYTES (Na, K, C l) 17-11-2024 11:28:PM
PH 7.34 SODIUM 140 mmol/L 145-136 mmol/L
PCO2 49.7 POTASSIUM 4.3 mmol/L 5.1-3.5 mmol/L
PO2 89.8 CHLORIDE 102 mmol/L 98-107 mmol/L
HCO3 26.6
St.HCO3 25.1
BEB 0.8
BEecf 1.5
TCO2 53.9
O2 Sat 96.4
O2 Count 17.4
:
65M clinical imageology of fever cough for months and a metabolic syn phenotype:
https://youtube.com/shorts/XzD68QDEa7I?si=IjbAAqbKLuvqeODM
Pajr PHR MODERATOR:
The other Afternoon IPD session is again a clinico radiology correlation of a 65M with marked bronchiectasis slightly different from the 18-21F discussed earlier. Other than a right prominent sternomastoid trail clue nothing very obvious suggesting volume loss on either side
[11/19, 4:20 PM] PaJR PHR Moderator: His clinical phenomenon is suggestive of metabolic syn although no documented hyperglycemia till date!
[11/19, 4:22 PM] PaJR PHR Moderator: 65M Grape like clusters more at peripheral left upper lobes unlike the 18-21F who had more of bilateral proximal bronchiectasis
HRCT revealing a large lung cyst in the left upper lobe, posteriorly placed and hence not visible in the earlier chest X-ray but visible here along with the other cystic bronchiectatic changes 👇
https://youtube.com/shorts/XzD68QDEa7I?feature=shared
