49 M PTB DENOVO DM

A 49yr old male patient resident of Yadadri presented to the pulmonology  OPD with chief complaints of  cough  since 10 days,cold since 10days,generalised weakness since 2months, decreased appetite since 20days.

 HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 25days back after which he developed cough with sputum which is  insidious in onset mucoid in nature , non foul smelling not bloodtinged went to local hospital but not subsided with treatment and came to us with progressing in nature,mucoprulent,foul smelling and non blood stained,cough is more atnight.

C/OHalitosis & Chest tightness-Present

C/O Loss of appetite

C/O Loss of weight-+,(59kgs-40kgs)in span of 6months

NO c/o fever,chestpain,shortness of breath,sweating,palpitations,↓urine output

HISTORY OF PAST ILLNESS:

No H/O of smilar complaints in the past.

Not a K/C/O DM,HTN,Thyroid,Epilepsy.

No H/O inhaler usage in the past.

No H/O TB in the past.

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

Diet-Mixed.

Appetite-Lost.

Bowel&Bladder Movements-regular.

Sleep-adequate.

Addictions-Alcohol:regular(stopped 1month back)

                  Tobacco chewing since 15yrs.

GENERAL EXAMINATION: 

patient is conscious,coherent and cooperative. 

well oriented to time,place and person.

thin built and moderately nourished. 

 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,pedal edema.

 

VITALS: 

BP -110/70 mmhg

TEMP- afebrile

RR-20 cpm

PR-86bpm

spO2- 98%@ra

GRBS-424

 

SYSTEMIC EXAMINATION:

CVS- S1S2 heard, no murmurs. 

CNS- No focal deficits. 

PA- soft, non tender.

 

RESPIRATORY SYSTEM:

URT:

Nose- NO polyps, dns,turbinate hypertrophy.

oral cavity- poor oral hygiene. 

Post pharyngeal wall- normal.

LRT:

Inspection:

Shape of chest : bilateral symmetrical,elliptical.

Trail sings:negative.

trachea: central.

no supra and infra clavicular hollowness.

chest expansions equal on both sides.

Spinoscapular distance equal on both signs.

no crowding of ribs.

no drooping of shoulders.

no wasting of muscles.

no usage of accessory muscles of respiration.

apical impulse not seen.

no scars,sinuses, engorged veins,visible pulsations.

no kyphosis ,scoliosis.

A large hypopigmented patch seen over anterior chest wall.

 

Palpation:

all inspectory findings are confirmed.

no local rise of temperature. 

no tenderness. 

trachea central

apex beat felt at 5th ICS,1inch medial to MCL.

TVF increased at right ISA.

 

Diameters:

ANTERO POSTERIOR : 28cm.

transverse: 24cm.

chest circumference: 84cm.

on inspection chest circumference:87cm.

right th-42cm

left th-41cm

                                     

Percussion:

Direct:resonant

Indirect:resonant,equal in all areas.

Cardiac dullness:normal limits.

Liver dullness:right 5th ics.

Kronigs isthmus:not oblituated.

Traube’s space:not oblituated.

 

Auscultation: 

BAE+

NVBS heard.

VR increased at right ISA.

INVESTIGATIONS:

HRCT:

·       Large irregular thick walled cavity seen in apical&post.segment of right upper lobe –mobile intracavitatory soft tissue content and small air fluid level-surrounding consolidation as described above-likely suggestive of lung abcess-possible rupture into bronchioles –superadded infection.suggested follow up after 3-6months.

·       Multiple centrilobular nodules are seen in both upper lobes&right middle lobes.

·       S/O endobronchial spread of infection.

·       Mediastinal lymphadenopathy.

Ssputum CBNAAT POSITIVE ON 7-1-2023.

 

PROVISIONAL DIAGNOSIS:

RIGHT UPPER LOBE CAVITATORY LESION WITH ASPERGILLOMA WITH DENOVO DM2.

TREATMENT:

·       Inj.piptaz 4.5gm/iv/tid.

·       Inj.metrogyl 500mg tid.

·       Inj.pan 40mg iv/od/bbf.

·       Syp.ascoril-ls 2tbsp/po/bd.

·       Syp.aptivate 10ml/bd.

·       Ivf ns 500ml@100ml/hr.

·       Inj.thiamin 100mg/iv/bd.

SOAP NOTES:

On 05/01/2024

C/o cough(mucoid)

No c/o sob,fever,hemoptysis.

·       Inj.piptaz 4.5gm/iv/tid.

·       Inj.metrogyl 500mg tid.

·       Inj.pan 40mg iv/od/bbf.

·       Syp.ascoril-ls 2tbsp/po/bd.

·       Syp.aptivate 10ml/bd.

·       Ivf ns 500ml@100ml/hr.

·       Inj.thiamin 100mg/iv/bd.

On 06/01/2024

c/o cough(mucoid) occasionally present.

No c/o fever,hemoptysis,chestpain,chest tightness.

·       Inj.piptaz 4.5gm/iv/tid.

·       Inj.metrogyl 500mg tid.

·       Inj.pan 40mg iv/od/bbf.

·       Syp.ascoril-ls 2tbsp/po/bd.

·       Syp.aptivate 10ml/bd.

·       Ivf ns 500ml@100ml/hr.

·       Inj.thiamin 100mg/iv/bd.

On 07/01/2024

c/o cough

no c/o sob,fever,hemoptysis,chest tightness,chest pain.

·       Inj.piptaz 4.5gm/iv/tid.

·       Inj.metrogyl 500mg tid.

·       Inj.pan 40mg iv/od/bbf.

·       Syp.ascoril-ls 2tbsp/po/bd.

·       Syp.aptivate 10ml/bd.

·       Ivf ns 500ml@100ml/hr.

·       Inj.thiamin 100mg/iv/bd.

On 8/01/2024

c/o cough-subsided,present occasionally.

No c/o fever,sob,chestpain,chest tightness,palpitations.

·       ATT↓NTEP 3tablets po/od/bbf.

·       Inj.piptaz 4.5gm/iv/tid.

·       Inj.metrogyl 500mg tid.

·       Inj.pan 40mg iv/od/bbf.

·       Syp.ascoril-ls 2tbsp/po/bd.

·       Syp.aptivate 10ml/bd.

·       Ivf ns 500ml@100ml/hr.

·       Tab.benadon 20mg po/od.

ADVISE AT DISCHARGE:

·       ATT 3tabs per day under NTEP bbf.

·       Inj.HAI 10U-10U-8U(7AM-1PM-7PM),NPH 10U-0-8U(7AM-7PM).

·       Tab.pan 40mg iv/od/bbf×1week.

·       Syp.aptivate 2tbsp/bd×1week.

·       Tab.benadon 40mg od×1month.

·       Diabetic diet&regular exercise.

·       Home GRBS monitoring n/f hypogenic symptoms.

·       High protein diet-2egg whites/day.

·       Syp.potklor 10ml in glass of water tid×3days.

PATIENT ATTENDERS WERE CONTACTED THROUGH PHONE CALL HIS WIFE TOLD THAT HE WAS DOING FINE AND COMPLETED TREATMENT AND WAS FOUND TO BE SPUTUM NEGATIVE.24-8-2023

OUTCOME- COMPLETELY RECOVERED