50 F PTB DM2

 PATIENT CAME WITH COMPLAINS OF COUGH WITH SPUTUM SINCE 15 DAYS,FEVER SINCE 15 DAYS , SHORTNESS OF BREATH SINCE 2 DAYS 

HISTORY OF PRESENTING ILLNESS 

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK , THEN SHE DEVELOPED COUGH WITH SPUTUM SINCE 15 DAYS WHICH IS WHITISH,MUCOID,NON FOUL SMELLING , NON BLOOD STAINED , NO AGGREVATING AND RELIEVING FACTORS . C/O FEVER SINCE 15 DAYS ,EVENING RISE OF TEMPERATURE ,LOW GRADE NOT ASSOCIATED WITH CHILLS.

C/O SHORTNESS OF BREATH SINCE 2 DAYS , GRADE 3 MMRC , NO WHEEZE , AGGREVATED ON EXCERTION , NO RELIEVING FACTORS. NO ORTHOPNEA, NO PND . C/O LOSS OF APPETITE , C/O LOSS OF WEIGHT 5KG IN 1MONTH. C/O CHEST PAIN ON RIGHT SIDE SINCE 2DAYS,NON RADIATING. BIOMASS EXPOSURE PRESENT SINCE 30YEARS. 

PAST HISTORY 

NO H/O SIMILAR COMPLAINTS IN PAST 

NO H/O TB IN PAST,NO INHALER USAGE NOT K/C/O DM,HTN,CAD,EPILEPSY,HYPOTHYRODISM 

PERSONAL HISTORY 

WEIGHT:60 KG 

OCCUPATION : HOUSEWIFE NON SMOKER BETEL LEAF CONSUMPTION OCCASIONALLY.

 FAMILY HISTORY : NOT SIGNIFICANT VITALS AT ADMISSION: TEMP:98.7F PR:112BPM RR:29CPM BP:110/80MMHG SPO2:90% 

 ON EXAMINATION AUSCULTATION BAE + VBS ABSENT BREATH SOUNDS AT RIGHT ICA,MA,AA,IAA,INTER SA,INFRA SA VR- DECREASED IN RIGHTICA,MA,AA,IAA,INTER SA,INFRA SA

Investigation

CBP -12-11-2023 HB : 13.7GM/DL TLC: 19400 CELLS/CUMMM PLATELET COUNT -3.67LAKHS EOSINOPHILS : 02 NEUTROPHILS : 94

LYMPHOCYTES:04 MONOCYTES:00 CBP 13/11/2023 HB: 12.6 GM/DL TLC : 13200 NEUTROPHILS : 87 LYMPHOCYTES : 10 EOSINOPHIL:01 MONOCYTE:02 PLATELET COUNT : 2.76 LAKHS 

CBP 15/11/2023 HB: 10GM/DL TLC : 8000 NEUTROPHILS : 83 LYMPHOCYTES : 14 EOSINOPHIL:01 MONOCYTE:02 PLATELET COUNT : 1.7 LAKHS LFT 12/11 17/11 18/11 

TB- 1.86 MG/DL 2.11 2.33

 DB- 0.24MG/DL 1.00 1.41 

SGOT- 19 19 25 

SGPT- 14 16 18 

ALKALINE PHOSPHATE : 185 115 162 

TOTAL PROTEINS : 7.1 4.8 5.5 

ALBUMIN - 4.1GM/DL 2.49 2.88 

A/G RATIO 1.37 1.08 1.10 

BLOOD UREA : 26 MG / DL 

RFT 12/11 13/11 15/11 16/11 18/11

 UREA-68 53 37 36 50

 CREATININE-1.61 1.5 1.4 1.5 1.4

 Na-129 128 130 125 124

 K-3.8 3.4 3.8 3.3 3.0

CL-97 95 98 98 98 

CUE 12/11 15/11 

ALBUMIN NIL TRACE 

SUGARS 4+ NIL 

PUS CELLS-2-3 2-3 

EPITHELIAL CELLS 2-3 2-3 

URINE FOR KETONES-NEGATIVE 

TROP I-9.6 CRP-2.4 

SEROLOGY-NEGATIVE 

2D ECHO:11/11/23 EF-69% IVC SIZE-0.8CM COLLAPSING RVSP2 22+10=32MMHG NO RWMA GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION ABSENT 2D ECHO 18-11-2023 EF-56% IVC SIZE-0.4CM COLLAPSING RVSP2 20 MMHG NO RWMA GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION PRESENT 

USG (13-11-2023) IMPRESSION GRADE 1 RPD CHANGES IN LEFT KIDNEY RAISED ECHOGENICITY OF RIGHT KIDNEY 

SPUTUM TRUENAAT POSITIVE ON 14/11/23 

PLEURAL FLUID TRUENAAT POSITIVE ON 14/11/23

 SPUTUM CULTURE AND SENSITIVITY 15/11/23 ZN STAIN-ACID FAST BACILLI SEEN(SCANTY) 

KOH MOUNT NO FUNGAL ELEMENTS SEEN 

GRAM STAIN-0-1 EPITHELIAL CELLS/LPF, >25PUS CELLS/LPF,FEW GRAM POSITIVE COCCI IN SINGLES SEEN. STREPTOCOCCUS PNEUMONIAE ISOLATED RESISTANT TO PENICILLIN,AMPICILLIN,CIPROFLOXACIN,COTRIMOXAZOLE,CEFTORIDIME,CEFUROXIME,ER YTHROMYCIN INTERMEDATELY SENSITIVE TO AMOXYCLAV SENSITIVE TO AZITHROMYCIN 

BLOOD C/S -NO GROWTH 

URINE C/E- NO GROWTH 

TUBE THORACOSTOMY DONE ON 11/11/23 UNDER STRICT ASEPTIC CONDITIONS BETADINE IS PAINTED OVER RIGHT HEMITHORAX, 2%XYLOCAINE IS INSTILLED IN 4TH ICS IN MIDAXILLARY LINE.AN ICD TUBE OF 24 FRENCH IS INSERTED AND IS PLACED AT MARK 8. PROCEDURE WAS UNEVENTFUL ICD NOTES: TUBE-PATENT DRAIN-NIL AIR COLUMN MOVEMENT:4-5CM H2O AIR LEAK ABSENT SUBCUTANEOUS EMPHYSEMA ABSENT ICD CARE: BAG ALWAYS BELOW WAIST CAP ALWAYS OPEN CHECK AIR COLUMN MOVEMENT MAINTAIN UNDER WATER SEAL 

TREATMENT: 1.HIGH FLOW OXYGEN @12-14LIT/MIN WITH FACE MASK

 2.INJ.TRAMADOL 1AMP IN 100ML NS/STAT 

TUBE THORACOSTOMY DONE ON 18/11/23 

UNDER STRICT ASEPTIC CONDITIONS BETADINE IS PAINTED OVER RIGHT HEMITHORAX, 2%XYLOCAINE IS INSTILLED IN 6TH ICS IN MIDAXILLARY LINE.AN ICD TUBE OF 24 FRENCH IS INSERTED AND IS PLACED AT MARK 10. PROCEDURE WAS UNEVENTFUL ICD NOTES: TUBE-PATENT DRAIN-50 ML AIR COLUMN MOVEMENT:4-5CM H2O AIR LEAK ABSENT SUBCUTANEOUS EMPHYSEMA ABSENT ICD CARE: BAG ALWAYS BELOW WAIST CAP ALWAYS OPEN CHECK AIR COLUMN MOVEMENT MAINTAIN UNDER WATER SEAL ADVISED 

1.HIGH FLOW OXYGEN 10-12LIT/MIN WITH FACE MASK

 2.INJ TRAMADOL 1 AMP IN 100 ML NS/STAT

 11/11/23 GM REFERRAL TAKEN I/V/O ECG CHANGES AND HIGH GRBS ADVISED-TROP-I AND 2D ECHO INJ-HUMAN ACTRAPID INSULIN 6U IV/STAT INJ HUMAN ACTRAPID INSULIN INFUSION 1ML IN 39ML NS 6ML/HR REVIEW REFERRAL TO GM DONE ON 12/11/23 ADVISED:INJ.HAI 1ML(40UNITS)IN 39ML NS 6ML/HR REVIEW REFERRAL TO GM DONE ON 13/11/23 ADVISED 

1.IV FLUIDS 75ML/HR 2.INJ HAI THRICE PREMEALS ACCORDING TO GRBS 3.SYP POTKLOR 15ML IN 1GLASS OF WATER PO/TID X 2DAYS 

OPHTHALMOLOGY REFERRAL DONE ON 13/11/23 I/V/O DIABETIC RETINOPATHY CHANGES. IMPRESSION:VERY MILD NON PROLIFERATIVEDIABETIC RETINOPATHY CHANGES NOTED ON FUNDUS EXAMINATIUON IN BOTH EYES AS OF NOW 

Treatment Given:

 1.ATT 4TAB/DAY UNDER NTEP BPF(DAY2) 

2.INJ.PIPTAZ 2.25GM IV/TID X5DAYS

 3.INJ.PAN 40MG IV BBF OD

 4.INJ.TRAMADOL 1AMP IN 100ML NS(SOS)

 5.TAB.PCM 650MG PO/TID 

6.INJ.NEOMOL 1GM IV SOS IF TEMP>101F 

7.SYP ASCORYL D PO/TID 2TBSP

 8.SYP ARISTOZYME PO/BD 2TBSP 

9.SYP POTCHLOR 15ML PO/TID 

10.INJ HAI S/C 30U-30U-30U PREMEAL 

11.TAB.BENADON 40MG PO/OD 

12.HIGH PROTEIN DIET/2EGG WHITES PER DAY