67/M WITH SOB AND FEVER

 UNIT 1 


AMC CUBICAL 2


DOA:04/06/23


A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of 


Shortness of breath since 1 week 


Fever since 4-5 days


HOPI :


Pateint was asymptomatic 1 week back then he developed shortness of breath grade 2-4 aggrevating on doing work, walking and temporarily relived on medication and fever for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital.


He also had fever since 4days high grade evening raise temperature associated with chills and rigors relieved by medication and increases again.


H/O decreased urine output since 6 months


C/o pain abdomen on &off left lumbar region since one week


C/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents


C/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling


C/o decrease in appetite since 1 week 


No c/o of chest pain , palpitations 


PAST HISTORY


He had history of hypertension since 10 years and on  medication 


TAB Olmesartan -H


No history of diabetes, thyroid,epilepsy,asthma,CAD ,CVA 


History of previous surgery Renal stunting 6 months back




PERSONEL HISTORY: 




Diet:mixed


Sleep:regular 


Appetite: decreased appetite since 1 month 


Bladder - decreased urine output with burning micturation since 1 month


Bowel movements are regular 


Addictions:he started taking chewable tobacco since 30 years and stopped one week back


He also had a history of taking alcohol since 25 years and stopped one year back




Family history: Not significant




Treatment history: 


Renal Stenting 6 months back




General examination::


Patient is conscious,cohorent , cooperative well known with time, place, person 


He is well built and moderately nourish.

Pallor present 






Icterus: Absent 


Cyanosis: Absent 


Clubbing: Absent 


Lymphadenopathy: absent 




VITALS:


TEMP:97.2F


PR:117bpm


RR:28cpm


BP:120/80


Spo2: 94% @4L 02


GRBS:128mg/dl




SYSTEMIC EXAMINATION:




RESPIRATORY SYSTEM:


Patient examined in sitting position


Inspection:-


Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 


Chest appears Bilaterally symmetrical & elliptical in shape


Respiratory movements appear equal on both sides and it's Abdominothoracic type. 


Trachea central in position & Nipples are in 5th Intercoastal space


No dilated veins,sinuses, visible pulsations.

Palpation:-


All inspiratory findings confirmed


Trachea central in position


Apical impulse in left 5th ICS, 1cm medial to mid clavicular line


Infraclavicular- (NVBS) (NVBS)


Mammary- (NVBS) (NVBS)


Axillary- (NVBS) (NVBS)


Infra axillary-(NVBS) (NVBS)                 


Suprascapular- (NVBS) (NVBS)


Interscapular- (NVBS) (NVBS)


Infrascapular- (NVBS)(NVBS)




CVS: 


Inspection : 


Shape of chest- elliptical 


No engorged veins, scars, visible pulsations


Palpation :


Apex beat can be palpable in 5th inter costal space


Auscultation : 


S1,S2 are heard


no murmurs


PER ABDOMEN








**Shape of abdomen-scaphoid


**Tenderness-No


** Palpable mass-No


** Liver- Not palpable


**Spleen - Not palpable


**Bowel sounds - Normal




Provisional Daignosis: left hydroneprosis secondary to ? left ureteric obstruction ? Post renal AKI


Investigations:- 














Treatment:


1.INJ LASIX 40 MG IV STAT


2.NEB WITH DUOLIN STAT  BUDECORT


3.INJ NEOMOL 1GM IV SOS


4.TAB DOLO 650MG PO/BD


5.TAB OLMESARTAN-H PO/BD


6.BP,PR,TEMP CHARTING 4TH HOURLY.




Treatment:-


1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg




11/6/23




Vitals:-


Temperature : 101 F


Pulse rate : 96 bpm


Blood pressure: 120/70mm Hg




Treatment:




1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg








12/6/23


Treatment:-




1.inj piptaz 2.2sqm IV 


2. IV fluid NS 75ml/hr


3.Inj neomol 1g IV Sos


4.tab dolo 650 mg BD


5.tab olmesartan 


6.Neb c duolin /budecort


7.tab pan 40 mg


8.syp alkaprose B6 5ml


9.Syp cremaffin 10ml 


10.tab tamsulosin 0.4 mg



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