40 YEAR OLD MALE WITH SOB

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. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

40 YEAR OLD MALE WITH SOB

40 year old male patient,resident of pothunuru came to casualty at night on 25/09/2022 with chief complaints of

-Fever since morning 

-SOB grade 4 (MMRC) since evening

History of present illness-

He is farmer by occupation.

Patient was apparently asymptomatic 20 years back.

Then developped B/L pedal edema(patient says truck tire has passed on his left leg and stone has fallen on his right leg)from then he started developping pedal edema(upto knee,pitting type) on and off.Not on any medication since 20 years.

pedal edema aggravates on sitting for longer duration and taking rest.relieves on walking for sometime

From 4days he was having decreased urine output and burning micturition

Yesterday night he consumed alcohol and next day he went to work at 9am.Returned to home for lunch at 1pm and went to work again

In the evening he developped fever(high grade) associated with chills and rigors 

He started developping breathlessness while working and went home.By night it slowly progresses to grade 4(mmrc).orthopnea present

Past history-

N/K/C/O-HTN,DM,TB,Asthma,Thyroid disorders,epilepsy


Family history-

No similar complaints seen in family members


Personal history-

Appetite-normal

Sleep-adequate

Diet-mixed

Bowel Movements-regular

Bladder movenents-decreased urine output and burning micturition since 4 days

Alcohol-Drinks from past 20 years(100ml per week)

Tobacco chewing since 10 years(occasionally)


General examination

Pallor-

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-B/L peda edema (upto knee,pitting type) on and off since 20 years

Vitals-

BP-100/70 mmHg

PR-114bpm

RR-38cpm

SPO2-88% at RA 

GRBS-122 mg/dl

TEMP-102.5°F


Systemic examination

=>CVS-S1S2+

             No thrills

             No murmurs


=>R/S-BAE+

          -Decreased breath sounds in b/l                           infrascapular areas

         -crepitations present in b/l                                    infrascapular areas

         -trachea central

         -no wheeze

         -orthopnea present

=>P/A-shape obese

          -soft and non tender

          -no organomegaly

=>CNS-patient is conscious coherent and  cooperative   

           -speech normal

           -no signs of meningeal irritation 

          -cranial nerves intact

          -NFND

Provisional diagnosis-

LRTI WITH RIGHT LOWERLOBE CONSOLIDATION

AKI

Investigations-

25/09/2022

Treatment-

1)INJ.DOXY 100MG/IV/BD

2)INJ.AUGMENTIN 1.2GM/IV/BD

3)INJ.LASIX 20MG/IV/BD

4)IVF NS @50 ML/HR

5)INJ.THIAMINE (200MG IN  100ML NS)OVER

MIN/BD

6)INJ.OPTINEURON 1 AMPULE IN 100ML NS

OVER 30 MIN /OD

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