60 F with left upperlobe cavity with consolidation sec to TB with DM 2

DOA : 4/1/2023
Discharge Date:11/01/2023
Ward:RICU
Unit:PULMONOLOGY
Diagnosis
LEFT UPPERLOBE CAVITY WITH CONSOLIDATION SECONDARY TO TB WITH DIABETESMELLITUS -2 ON ATT DAY 2 (IP).
Case History and Clinical FindingsCOMPLAINTS OF COUGH SINCE 15DAYSFEVER SINCE 15DAYSBREATHLESSNESS SINCE 15DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 15DAYS BACK AFTER WHICH HE DEVELOPEDCOUGH INSIDIOUS IN ONSET MUCOID IN NATURE WITH BLOOD IN SPUTUM 4-5 DAYSEPISODES <10ML HE VISITED LOCAL HOSPITAL NO AGGREVATING FACTORS
FEVER WITH CHILLS RIGORS ASSOCIATED WITH VOMITINGS NON BILIOUS 2 EPISODESSOB GRADE II NOT ASSOCIATED WITH WHEEZING ,NO ORTHOPNEA PND NO SEASONALVARIATIONS
HISTORY OF LOSS OF WEIGHT SINCE 1MONTH ,COMPLAINS OF GENERALISED WEAKNESSS
COMPLAINTS CHEST TIGHTNESS
NO HISTORY OF SWEATING ,PALPATATIONS ,DECREASED URINE OUTPUTK/C/O DM ON MEDICATIONS ORAL HYPOGLYCEMIES ON T.METFORMIN
+GLIMEPIRIDE+T.VOGLIBOSESINCE 8YEARS


N/K/C/O HTN,BRONCHIAL ASTHMA ,THYROID DISORDERS
,EPILEPSY.AUSCULTATION-BAE PRESENT
ABSENT BS AT LEFT INFRA SA
VOCAL RESONANCE- DEC EASED AT LEFT ISA, INFRA SA, IAA, MA
Investigation
4/1/23 - NO SONOLOGICAL ABNORMALITY DETECTED.
5/1/23 - 2D ECHO - AORTIC VALVE CALCIFICATION, THICKENED ,NO RWMA, MILD LVH,RVSP
35 MMHG,IVC SIZE - 0.8 CMS COLLAPSING,MILD TO MODERATE AS,TRIVIALAR,MR,TR,SCLEROTIC AV,GOOD LV SYSTOLIC FUNCTION,DIASTOLIC DYSFUNCTIONPRESENT, AORTIOC FLOW MPG - 45.05 MMHG,PPG - 30.09MM HG.
10/1/23 SPUTUM CBNAAT - POSITIVE
OPHTHALMOLOGY REFERRAL WAS TAKEN ON 7/1/23 I/V/O FUNDOSCOPIC CHANGES FORDIABETIC RETINOPATHY
IMPRESSION - ON FUNDOSCOPY NO FEATURES OF DIABETIC RETINOPATHY
GM REFERRAL WAS TAKEN ON 6/1/23 I/V/O DERRANGED BLOOD SUGAR, THEY ADVISEDFOR HAI ACCORDINGLY WITH GRBS SCALE, REVIEW REFFERAL WAS TAKEN ON 10/1/23AND THEY ADVISED TAB. GLIMI M2 PO/BD,STOP INSULIN ,STRICT DIABETIC DIET

Treatment Given(Enter only Generic Name)
INJ TRANEXA 500MG SOS
TAB ETHAMSYLATE 250MG BD
INJ CEFTRIAXONE 1GM IV/BD X 7 DAYSINJ PAN 40MG OD/IV BD
SYP GRILINCTUS-DX 2TBSP PO/BDTAB.PCM 500MG PO/BD
TAB AZEE 500MGOD X5 DAYSATT 4TABS PER DAY FROM 10/1/23TAB BENADON 40 MG PO OD
TAB GLIMI - M2 PO BD
Advice at Discharge
ATT 4 TABS PER DAY UNDER NTEPTAB PAN 40 MG PO OD X 1WEEK


TAB BENADON 40 MG PO OD X 1 MONTHTAB GLIMI M2 PO BD X 1 MONTH
STRICT DIABETIC DIET
SYP GRILINCTUS-DX 2TBSP PO/BD
HIGH PROTEIN DIET - 2 EGG WHITES PER DAYPROTEINEXPOWDER2TSPIN1GLASSOFMILKBD

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