A 62 YEAR OLD MALE WITH WITH SOB LOSS OF APPETITE AND COUGH
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This is a case of a 62 year old male agricultural labourer by occupation who presented with the chief complaints of :
shortness of breath since one month
loss of appetite since 20 days
Patient was apparently asymptomatic one month ago then he developed shortness of breath since one month which was sudden in onset and gradually progressive occuring on exertion associated with dry cough which occurs on prolonged dyspnea aggravated on exertion and relieved on lying.
He developed SOB which occurred even at rest in sitting posture 10 days ago
He complains of sudden loss of appetite since 20 days due to which he lost 5-6 kgs
He was then taken to a local hospital a week after the symptoms appeared, then to a tertiary care hospital in Hyderabad a week ago where he was told to have his sr.creatinine levels raised, he was then referred here for dialysis.
Past history
He had a right knee fracture 5 years ago. Surgery was done during which he was diagnosed to have Hypertension and diabetes for which he was put on medications
Aten-20 for hypertension
Metformin 500 mg for diabetes
He couldn't commence his daily routine work since he had fracture. He uses a stick to walk.
Family history-
No significant family history
Personal history:
Diet - mixed
Appetite- lost
Sleep - adequate
Bowel and bladder movements- regular
He is a smoker since 2-3 years (1 beedi per day).
General physical examination-
Patient is examined under well lit room and adequate ventilation with consent taken
He is concious coherent cooperative moderately built and nourished
Pallor icterus clubbing cyanosis lymphadenopathy pedal edema absent
Temperature- afebrile
Blood pressure 110/80
Pulse rate- 82 bpm
Respiratory rate- 14 cpm
Systemic examination:
Respiratory system-
No dyspnea
On inspection
Shape of chest - bilaterally symmetrical, elliptical
Movement of chest wall - symmetrical, normal anteroposterior
Palpation
Position of trachea - central
Symmetrical chest expansion
Percussion-
Resonance heard bilaterally in all areas of percussion
Auscultation-
Normal vesicular breath sounds heard in all areas of auscultation
No wheeze
No rhonchi, crepts
Abdomen-
Shape - scaphoid
No scars swellings sinuses seen
On palpation-
Non tender, soft, liver spleen not palpable
On auscultation-
Bowel sounds heard
Cardiovascular system-
S1 S2 heard. No murmurs and thrills
Central nervous system-
NFND
Reflexes +
Investigations-
HRCT chest-
CBP-
RFT-
LFT-
USG-
Provisional diagnosis-
Acute kidney injury on chronic kidney disease 2° to diabetic nephropathy? with cystic bronchiectasis
Treatment-
Inj.lasix 40mg i.v. BD
Inj. Pan 40mg i.v. OD
Inj. Zofer 4mg i.v. OD
Tab.MVT PO/OD
Tab. Nodosis PO/OD
Tab. Orofer XT 20mg OD
GRBS 4th hourly, monitor vitals
Tab. Nicardia 10mg PO/OD
Inj. Augmentin 1.2g i.v. BD
Tab. Shelcal PO/OD
Tab. Atenelol 25mg PO/OD
Neb. Duolin
Discussion-
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