78M with LEFT SIDED FIBROSIS ( LL>UL) WITH COPD WITH SECONDARY INFECTION WITH PTB WITH DIABETES MELLITUS -II

DOA : 20/1/2023
Discharge Date
Date:27/01/2023
Ward:RICU
Unit:PULMONOLOGY

Diagnosis
LEFT SIDED FIBROSIS ( LL>UL) WITH COPD WITH SECONDARY INFECTION WITH PTB WITHDIABETES MELLITUS -II

Case History and Clinical Findings
CHEIF COMPLAINTS:C/O BREATHLESSNESS SINCE 7 DAYS.C/O COUGH SINCE 7 DAYS.
C/O THROAT PAIN SINCE 3 MONTHS.

HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY NORMAL UNTIL 3 MONTHS BACKAFTER WHICH HE DEVELOPEDTHROAT PAIN WHICH IS INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVEAND DYSPHAGIATO BOTH SOLIDS AND LIQUIDS.
C/O BREATHLESSNESS SINCE 7 DAYS ,INSIDIOUS IN ONSET GRADUAL;LY PROGRESSIVEAGGRAVATED ON EXPOSURE TO COLD SEASONAL VARIATION ASSOCIATED WITHWHEEZENO ORTHOPNEA,NO PND.
C/O DRY COUGH SINCE 7 DAYS,CONTINUOUS,NO AGGRAVATING AND RELEIVINBGFACTORS.
C/O LOW GRADE FEVER OCASSIONALLY,NOT ASSOCIATED WITH CHILLS AND RIGORSC/O CHEST PAIN,CHEST TIGHTMESS,HEMOPTYSIS
C/O WEIGHT LOSS AND LOSS OF APPETITE
H/O PTB 4 YRS BACK CONFIRMED BY SPURTUM CBNAAT AND TOOK ATT.FOR 3 MONTHS
and discontinued.
USED 4 MONTHS THEN STOPPED 6 YRS BACK.AFTER 1 YEAR USED 4 MONTHS.3 YRS BACK7 MONTHS.
H/O SIMILAR COMPLAINTS IN THE PAST ,INHALER USAGE PRESESNT ON AND OFF,LASTUSED YESTERDAY.
K/C/O DM AND ON MEDIACTION
N/K/C/O HTN,THYROID,EPILEPSY,CAD.?LEFT SIDE EFFUSIONOCCUPATION - TODDY CLIMBER
BURNING MICTURITION PRESENTOCCASIONAL ALCHOLOIC.
SMOKING-2 PACKS/DAY (BEEDI) STOPPED 10 YEARS BACK

VITALS DURING ADMISSION- 
TEMP- 99 F
PR-130 BPMRR-20 CPM
BP-120/70 MM/HGSPO2-92% @ RA
AUSCULTATION FINDINGS:
BAE+,VBS
CREPTS+LEFT ICA,MA,IAA,SSAQ,ISA,INFRA SARIGHT ISA,INFRA SA,IAA
VR-INCREASED L ICA,MA,IAA,ISA,INFRA SA.

Investigation
2D ECHO ON 20/01/23:
AORTIC VALVE:SCLEROTICNO RWMA
EF:60 PERCENT
MILD TO MODERATE TR WITH PAH.DIASTOLIC DYSFUNCTION.HRCT OF THORAX ON 20/01/23:
FIBROCAVITATORY CHANGES WITH TRACTION BRONCIECTASIS IN BOTH UPPER LOBESWITH SIGNIG=FICANT VOLUME LOSS OF LEFT UPPER LOBE.
MULTIPLE CENTRILOBULAR NODULES IN BOTH LUNGS.
DIFFUSE SMOOTH PLEURAL THICKNING SEEN IN LEFT COSTAL MARGIN OF PLEURA WITHFEW PLEURAL CALCIFICATION WITH LOCULATED FLUID COLLECTION-SUGGESTIVE OFCHRONIC EMPYEMA/FIBROTHORAX
USG NECK21/1/23:NORMAL STUDY.
SPUTUM FOR CULTURE AND SENSITIVITY 22/1/23 : ACID FAST BACILLI SEEN (2+)SPUTUM CBNAAT 24/01/23 - POSITIVE
21/1/23 ;ENT REFERRALI/V/O DIFFICULTY INSWALLOWINGADVICE:UPPER GI ENDOSCOPY,USG NECK,XRAY NECK AP AND LATERAL.21/1/23:GM REFERRAL I/V/O HIGH BLOOD SUGARS
ADVICE:STRICT DIABETIC DIETTAB.GLIMI M1 PO/BD
GRBS 6TH HRLY.
25/1/23; GM REFERRAL I/V/O HYPONATREMIA AND ECG CHANGES
ADVICE: URINARY ELECTROLYTES, SERUM OSMOLALITY, REPEAT SERUM ELECTROLYTES,REPEAT ECG
1 PINT NS @50ML/HR FOR 6 HOURS
26/1/23: GM REFERRAL I/V/O HYPONATREMIA AND TACHYCARDIAADVICE: IVF NS @ 50ML/HR
TAB. METXL 12.5MG X 10 PO/OD- 8AM
TAB. ECOSPRIN -AV 75/20 MGX PO/ HS - 8PM

Treatment Given(Enter only Generic Name)
1. ATT ( 3 TABS) UNDER NTEP BBF ( STARTED ON 25/01/2023 )2.INJ.CEFTRIAXONE 1GM/IV/BD x 5 days
INJ.PAN 40MG/IV/OD/BBF
TAB.PCM 650MG PO SOS
SYP.GRILLINCTUS 2 TSP PO TID
SYP.APTIVATE 2 TSP PO BD
NEB. WITH DUOLIN 8TH HRLY,BUDECORT 12TH HRLY
TAB.GLIMI-M1 PO /BD
TAB.MET XL 12.5MG PO/OD 8AM
TAB.ECOSPRIN - AV 75/20 MG X PO/OD 8PM

Advice at Discharge
ATT (3TABS) UNDER NTEP BBF
TAB.PAN D 40MG PO/OD BBF X 3 DAYS
TAB.GLIMI M1 PO/BD X 8AM--o--8PM
SYP.GRILLINCTUS D X 2TSBP PO/TID X 5DAYS
SYP.APTIVATE 2TSBP PO/BD X 10 DAYS
DIABETIC PROTEIN POWDER IN 1 GLASS OF MILK /BD
TAB.BENADON 20MG PO/OD
2 EGG WHITES/DAY
TAB.MET XL 12.5MG PO/OD AT 8AM
TAB.ECOSPRIN AR 75/10 PO/OD AT 8PM
TAB.PCM 650MG PO/SOS

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