67/M PTB WITH UNCONTROLLED TYPE 2 DM , HTN 15 YRS

 A 67 YR OLD MALE, RESIDENT OF NALGONDA, CAME TO THE CASUALTY WITH CHIEF COMPLAINTS OF HEMOPTYSIS FROM 3 MONTHS.

HISTORY OF PRESENT ILLNESS 

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 YRS BACK WHEN HE STARTED TO DEVELOPTINGLING SENSATION IN  B/L UL AND LL AND GIDDINESS ON WAKING UP EARLY IN THE MORNING.
HE THEN DEVELOPED DIMINISION OF VISION IN THE LEFT EYE SINCE 5 YRS.
SINCE 8 MONTHS, HE HAS BEEN HAVING FEVER ASSOCIATED WITH CHILLS, CONTINUOUS TYPE, LOW GRADE, ASSOCIATED WITH BURNING MICTURATION, NOT ASSOCIATED WITH ANY DIURNAL VARIATION .
6 MONTHS AGO, HE BEGAN TO DEVELOP COUGH WITHOUT SPUTUM BUT GRADUALLY BECAME PRODUCTIVE, WHERE SPUTUM WAS MUCOID, WHITISH YELLOW. THEN, IT PROGRESSED TO BLOODY SPUTUM SINCE 3 MONTHS . 
SOMETIMES COUGH IS FOLLOWED BY VOMITING EPISODES WITH VARIABLE CONTENTS.
H/O WT LOSS OF 20KG IN 6 MONTHS 
ASSOCIATED WITH CONSTIPATION. ( PASSES STOOLS ONCE IN 3 DAYS )
SINCE 3 MONTHS, HE HAS BEEN HAVING EPISODES OF VOMITINGS, 1 EPISODE AFTER FOOD EVERYDAY WITH FOOD AS CONTENT.
HE ALSO COMPLAINS OF DRY MOUTH, POLYPHAGIA, POLYDYPSIA, POLYURIA, NOCTURIA.
NO COMPLAINTS OF LOSS OF APPETITE.

PAST HISTORY 

HE IS A K/C/O DM TYPE 2 SINCE 20 YRS AND IS ON TAB GLYPIZIDE+METFORMIN
AND HTN  SINCE 15 YRS AND IS ON TAB ATEN-AT 25/10
NOT K/C/O EPILEPSY, ASTHMA, TB,CVA,CAD

PERSONAL HISTORY:
SLEEP: ADEQUATE
APPETITE: NORMAL
DIET: MIXED
OCCUPATION DAILY WAGE LABOURER
BOWEL: IRREGULAR
BLADDER: BURNING MICTURATION 
ADDICTIONS: CONSUMED ALCOHOL 20 YRS AGO, NOW STOPPED
NON SMOKER

NO SIGNIFICANT FAMILY HISTORY 

GENERAL EXAMINATION:
DONE AFTER OBTAINING CONSENT, IN THE PRESENCE OF ATTENDER, WITH ADEQUATE EXPOSURE

HE IS CONSCIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME PLACE, MODERATELY BUILT AND NOURISHED

NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 

VITALS AT ADMISSION:
TEMP: 98 F
PR: 88BPM
RR: 20CPM
BP: 110/90MMHG LEFT ARM SUPINE POSITION 
SPO2: 98% ON ROOM AIR
GRBS: 410MG/DL

SYSTEMIC EXAMINATION:
CVS: S1, S2 HEARD
PA: SOFT, NON TENDER, BS PRESENT
CNS: NO FOCAL ABNORMALITY 

RESPIRATORY SYSTEM:

INSPECTION: 
RT SIDE INCREASED BREATH SOUNDS
TRACHEA TO THE RIGHT

PALPATION:
DECREASED BREATH MOVEMENTS ON THE RIGHT

PERCUSSION:
RIGHT MAMMARY DULL, REST RESONANT

AUSCULTATION:
VESICULAR BREATH SOUNDS HEARD, NO CREPTS, NO RONCHI

INVESTIGATIONS:
on 9/12/22











Pulmonology referral was taken 







TREATMENT:
9/12/22
IVF NS
INJ NEOMOL 1G IV SOS
TAB ATEN AT 25/5
SYP AMBROXOL 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS

10/12/22

IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP AMBROXOL 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD
ETHAMBUTOL 825MG PO OD
TAB BENFOMET PLUS 40MG PO OD



11/12/22

IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
TAB BENFOMET PLUS 40MG PO OD
INJ TRANEXA 500MG IV STAT TO SOS
TAB ETHAMSYLATE 250MG TID
( D1 ) INJ VIT K 2 AMP 

12/12/22

IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
INJ TRANEXA 500MG IV STAT TO SOS
TAB ETHAMSYLATE 250MG TID
INJ VIT K 1 AMP IN 100ML NS
TAB BENDON PO OD

13/12/22

IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
INJ TRANEXA 500MG IV STAT TO SOS
INJ VIT K 1 AMP IN 100ML NS
TAB BENDON PO OD

14/12/22

IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
INJ TRANEXA 500MG IV STAT TO SOS
INJ VIT K 1 AMP IN 100ML NS
TAB BENDON PO OD

15/12/22
IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
INJ TRANEXA 500MG IV STAT TO SOS
TAB BENDON PO OD
SYP CREMAFFIN PLUS 20ML PO HS

16/12/22
IVF NS
INJ NEOMOL 1G IV SOS
TAB AMLO PO OD
SYP GRILLINCTUS 10ML TID
INJ HAI SC TID ACC TO GRBS
TAB DOLO 650 PO SOS
TAB NEUROBIONE FORTE PO OD
TAB SHELCAL 500 PO OD
TAB ATT ACC TO WT 3 TABLETS 
ISONIAZID 225MG PO OD
RIFAMPICINE 450MG PO OD
PYRAZINAMIDE 1200MG PO OD 
ETHAMBUTOL 825MG PO OD
TAB BENDON PO OD


ATT STARTED ON 11-12-2023 
PATIENT CAME FOR FOLLOW UP IN FEB 2023 TO PULMONOLGY OPD AT KIMS NKP AND IS TAKING MEDICATIONS REGULARLY.COUGH AND  HEMOPTYSIS SUBSIDED.

Patient was contacted through phone call on 27-7-2023
Patient is c/o cough since 1 month and patient is still continuing ATT as advised by local doctors in mothukur
Patient is going for regular follow up once a month to mothukur government hospital, he is receiving att from mothukur government hospital.

ADVISED the patient to visit our hospital to evaluate further.

Contacted the patient on 31-10-2023 , to my suprise he is still using ATT as BD dose ( 1 tablet in the morning and night )as  advised by local practitioner. He complains of shortness of breath grade 1-2 . His cough and hemoptysis subsided.
Advised the patient to visit our institution to evaluate further.

contacted patient on 26-01-2024 , He is continuing ATT as TID dose as adviced by local RMP .He has no symptoms and advised the patient to visit our hospital for follow up and counselled about ATT.

On 15-04-24 contacted the patient through call - stopped ATT on 25-03-2024 , sputum TRUNAAT negative was done in mothkur and adviced by general physician to stop ATT .patient has no complaints now.

OUTCOME : RECOVERED COMPLETETLY - 1 YEAR 4 MONTHS

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