63M PTB

 63 YEAR OLD MALE CAME TO PULMONOLOGY OPD WITH 

 C/O COUGH SINCE 15 DAYS

BACK PAIN SINCE 3 MONTHS

2 EPISODES OF BLOOD VOMITINGS 15 DAYS BACK 

HISTORY OF PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE HAD 1 EPISODE OF HEMATEMESIS FOR WHICH PT WAS ADMITTED IN A LOCAL HOSPITAL AND WAS CONSERVATIVELY MANAGED AND THEN HAD A SIMILAR COMPLAINT 5 DAYS LATER AND WAS CONSERVATIVELY MANAGED PATIENT DEVELOPED COUGH 15 DAYS AGO SUDDEN IN ONSET PREDOMINANTLY NON PRODUCTIVE OCCASIONALLY PRODUCTIVE WHITISH

MUCOID SPUTUM, NON FOUL SMELLING OCCASIONALLY BLOOD STAINED ( LAST 4 DAYS AGO) 

MUCOID SPUTUM ,NON FOUL SMELLING OCCASIONALLY BLOOD STAINED ( LAST 4 DAYS

AGO) .

C/O FEVER LOW GRADE NOT AW CHILLS AND RIGORS AGGREVATED AT NIGHT

NO C/O SOB, CHEST PAIN, CHEST TIGHTNESS, SWEATING, PALPITATIONS, LOSS OF APPETITE, LOSS OF WEIGHT

PATIENT ALSO HAD THE C/O BACK PAIN SINCE 3 YRS AGGREVATED SINCE 3 MONTHS

C/O HOARSENESS OF VOICE SINCE 1 WEEK

H/O SIMILAR COMPLAINTS HEMATEMESIS 3 YRS BACK

NO H/O INHALER USAGE

PAST HISTORY

N/K/C/O DM,HTN, TB, CAD,EPILEPSY, THYROID DISORDER.

H/O ? CVA 10 YRS AGO NO DOCUMENTATION) 

H/O ? PLEURAL EFFUSION 10 YRS AGO(NO DOCUMENTATION)

PERSONAL HISTORY 

DIET-MIXED

APPETITE-NORMAL

BOWEL AND BLADDER MOVEMENTS-REGULAR

H/O ALCOHOL INTAKE REGULARLY 90-180ML/DAY FOR 20 YEARS, OCCASIONALLY SINCE 10

DAYS

H/O SMOKING 1PACK BEEDI/DAY FOR 20 YEARS STOPPED SINCE 10 DAYS

GENERAL EXAMINATION:

VITALS:

TEMP:97.8F

PR:86 BPM

RR:20 CPM

BP:100/70 MM OF HG 

SPO2: 98% ON ROOM AIR 

GRBS: 110MG/DL

EXAMINATION OF RESPIRATORY SYSTEM

UPPER RESPIRATORY TRACT

NOSE- NO DNS, NO POLYP ORAL CAVITY- NICOTINE STAINED TEETH PRESENT POSTERIOR PHARYNGEAL WALL NORMAL

LOWER RESPIRATORY TRACT

INSPECTION

SHAPE OF THE CHEST APPEARS TO BE ELLIPTICAL, B/L SYMMETRICAL TRACHEA-APPEARS TO BE CENTRAL

CHEST MOVEMENTS- APPEARS TO BE EQUAL ON BOTH SIDES

APEX BEAT- NOT SEEN

NO SUPRACLAVICULAR AND INFRACLAVICULAR HOLLOWNESS

NO USAGE OF ACCESSORY MUSCLES AND RESPIRATION

NO CROWDING OF RIBS, DROOPING OF SHOULDERS, WASTING OF MUSCLES

NO KYPHOSIS, SCOLIOSIS

NO SCARS, SINUSES, ENGORGED VEINS, VISIBLE PULSATIONS PALPATION

NO LOCAL RISE IF TEMPERATURE, NO TENDERNESS ALL INSPECTORY FINDINGS ARE CONFIRMED TRACHEA-CENTRAL

CHEST MOVEMENTS- EQUAL ON BOTH SIDES

VOCAL FREMITUS- EQUAL ON BOTH SIDES

AP DIAMETER- 21CM, TRANSVERSE DIAMETER- 26CM CHEST CIRCUMFERENCE - 1 - 81CM; E - 79 CM RIGHT HT - I - 41 CM ; E - 40 CM LEFT HT - 1 - 41CM; E - 40 CM PERCUSSION DIRECT- RESONANT

INDIRECT - IMPAIRED NOTE IN LT SSA, INTERSA AUSCULATATION BAE +, NVBS

BBS+ LT SSA

B/L FINE CREPTS + IN LT INFRA SA, IAA VOCAL RESONANCE- INCREASED IN LT SSA, INTER SA, ICA

GENERAL SURGERY REFERRAL DONE ON 26/3/24 I/V/O SWELLING IN NECK REGION DIAGNOSIS- ?LIPOMA/FIBROMA/FIBROLIPOMA OVER NAPE OF NECK

?LATERAL ABERRANT THYROID

ADVICE USG NECK AND THYROID PROFILE, FNAC OF BOTH SWELLING IN FRONT OF NE AND BACK

GENERAL MEDICINE REFERRAL DONE ON 26.03.24 for RFT CHANGES and they 

ADVICED

IV FLUIDS 75ML/HR

INJ.LASIX 20MG IV STAT

STRICT INPUT/OUTPUT CHARTING

REPEAT RFT SAMPLE TOMORROW AND ADVISED FOR USG ABDOMEN AND PELVIS 

I/V/O RPD CHANGES

CUE

COLOUR- PALE YELLOW

APPEARANCE- CLEAR

REACTION- ACIDIC

SPECIFIC GRAVITY- 1.01

ALBUMIN- ++

SUGAR- NIL

BILE SALTS- NIL

PIGMENTS- NIL

PUS CELLS- 3-4

EPITHELIAL CELLS- 2-3

RBCS- NIL

CRYSTALS- NIL

CASTS- NIL

AMORPOUS DEPOSITS- NIL

OTHERS-NIL

RFT 26/3/24>27/3/24.

UREA- 71MG/DL -72Mg/DL

CREATININE- 1.3 MG/DL --> 2.6MG/DL

URIC ACID- 6.2 MG/DL---

PHOSPHOROUS 3 MG/DL

SODIUM- 143MEQ/L—> 137

POTASSIUM- 3.2 MEQ/L--> 3.9

CHLORIDE 101 MEQ/L

TOTAI BILIRUBIN- 0.61MG/DL

DIRECT BILIRUBIN-0.18 MG/DL

SGOT- 16 IU/L

SGPT- 11 IU/L

ALP- 124 IU/L

TOTAL PROTEINS- 7.2 G/DL

ALBUMIN- 3.47 GM/DL

A/G RATIO- 0.93

26/3/24

BGT - A POSITIVE BT- 2MIN 30 SEC

CT 4MIN OO SEC

APTT 31 SEC

PT 15 SEC

INR 1.11

CRP- 2.4 MG/DL

ESR- 10MM/1ST HR

HBsAg-RAPID -Negative

ANTI HCV-NON REACTIVE

HIV 1/2 RAPID - NON REACTIVE

30/3/24

СВР:

HB- 10.4 GM/DL

30/3/24

СВР:

HB- 10.4 GM/DL

TLC- 9100 CELLS/CUMM

NEUTROPHILS- 76%

LYPHOCYTES 16%

EOSINOPHILS- 4%

MONOCYTESS-4% BASOPHILS-0 %

PLTCOUNT- 3.04LKHS/CUMM

SMEAR-normocytic normochromic

HRCT OF CHEST ON 26/3/24

IMPRESSION: CONSOLIDATION IN LEFT LUNG UPPER LOBE WITH AREAS OF CAVITATION AND MILD VOLUME LOSS

MILD FIBROSIS AND NODULES IN APICAL SEGMENTAL OF RIGHT LUNG UPPER LOBE

USG SWELLING (26.03.24)

IMPRESSION:

TIRADS-2 LESION ON RIGHT SIDE

LIPOMA AT NAPE OF NECK

USG ABDOMEN AND PELVIS (27.03.24)

IMPRESSION

CHOLELITHIASIS

B/L KIDNEYS SHOW GRADE 2 RPD CHANGES WITH RIGHT SIMPLE RENAL CORTICAL CYST

SPUTUM FOR TRUNAT: NEGATIVE

SPUTUM SENT FOR CULTURE SENSITIVITY- NEGATIVE

BAL SENT FOR TRUNAAT POSITIVE

MTB DETECTED 

29/3/24

BRONCHOSCOPY WAS DONE

UNDER STRICT ASEPTIC CONDITIONS WITH LOCAL ANAESTHESIA, BRONCHOSCOPY W PASSED THROUGH RIGHT NOSTRIL. UPPER RESPIRATORY TRACT WAS NORMAL, VOCI CORDS WERE NORMAL, LEFT PULMONARY BRONCHUS WAS NORMAL, LEFT SIDED APICOPOSTERIOR BRONCHOPULMONARY SEGMENTS WERE NORMAL, BRONCHIAL WASHING WAS COLLECTED FROM THE SEGMENTS AS THEY SHOWED BLOOD TINGED LEFT SIDED PRIMARY BRONCHUS WERE REMOVED, BRONCHOPULMONARY SEGMENT SHOWED NO EDEMATOUS CHANGES AND APICAL ANTEROPOSTERIOR, MIDDLE, LATER AND MEDIAL SEGMENTS SHOWED BLOOD CLOTS. LEFT SIDED BRONCHIAL WASHING TAKEN. PROCEDURES UNEVENTFUL. PRE AND POST POCEDURE VITALS WERE NORM.

TREATMENT GIVEN

BAL SENT FOR CULTURES; REPORTS AWAITED Treatment Given(Enter only Generic Name)

INJ. CEFTRIAXONE 1GM IV/BD X 5 DAYS

INJ PAN 40 MG IV/OD/BBF X 5 DAYS

IV FLUIDS 75ML/HR F/B IV FLUIDS- UO + 30ML/HR INJ.LASIX 20MG IV STAT

INJ.PCM 100ML/IV IF TEMP > 100 F

TAB. TRANEXA 500MG IV/TID X 5 DAYS TAB.PCM 650 MG PO/TID X 5 DAYS TAB.NODOSIS 500MG PO/BD X 4DAYS TAB.SHELCAL-CT PO/OD X 4 DAYS TAB.ULTRACET PO/BD x 5DAYS SYP. ARISTOZYME 2TSP/PO/TID SYP. GRILLINCTUS-DX 2TBSP/PO/TID

HIGH PROTEIN DIET

SALT RESTRICTION <2GM/DAY

LATER PATIENT WAS STARTED ON ATT 4 tabs / day ON OP BASIS after receiving BAL TRUNAAT REPORT