65 year old male presented with the complains of shortness of breath and fever

January 22, 2023
 This is a online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patients problems through series of inputs from available global community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This E log book also reflects my patient centered online learning portfolio and your valuable inputs in comment box is welcome.
 
A 65 years old Man Who is Resident of Narketpally who was Alcohol ( Sara ) Seller & Shepherd by Occupation Came with C/O 
Fever Since 3 Days.
HOPI : 
At 10 years of Age Patient Was apparently Asymptomatic Till 10 years of Age & Once day He Climbed & Fell Down While Cutting Tree leaves for feeding Their Goats & Had a Fracture of Lt.Forearm & Went to Nalgonda District Hospital where Cast was applied & After 20 days He developed infection & a part of Bone was Protruded out & That part of Bone was excised.
10 years Back : 
After Having a alcohol Binge Patient Developed Generalized Weakness & Got admitted in Our Hospital for 4-5 days
7 years Back : 
Patient Developed Giddiness & Went hospital & was diagnosed with DM2 & HTN for which he was Prescribed Tab.METFORMIN 500mg
Tab.AMLONG 5mg 
6 Months Back : 
Patient Developed Both Lower Limb Swelling which was Pitting type & Upto Knees & Diagnosed to have Left Upper Ureter Calculi & CKD For which he was planned for Surgery But Couldn't not be done as patient wasn't fit for Surgery & Was Managed Conservatively with Tab.NODOSIS 500mg BD.He Has Dry Cough Occasionally Since 6 Months & 3 Days Back Then Had Fever with Chills Which was High Grade Continuous & Relieved on Taking Medications.
Personal History: 
Patient Used to Sell Alcohol ( Sara) for almost 20 years & Used to Drink Daily the Same thing he used to Sell. Then he used to Drink 90-180ml of Whisky Till 6 Months Back & From Six Months He Drinks Occasionally During Festivals.


PERSONAL HISTORY:

Appetite : Decreased

Diet : Mixed

Bowel and bladder : Regular

Sleep : Adequate

Pt is conscious coherent and cooperative well oriented to time place and person

Pallor : Present

Cyanosis : Absent

Clubbing : Absent

Lymphadenopathy : Absent

Pedal Edema: pitting type extending upto knee joint 

Systemic examination: 



RESPIRATORY SYSTEM:

Inspection:

Shape- elliptical 

B/L symmetrical , 


Decreased movements on right side mammary region, infra scapular region  .

Engorged veins on the left side 

No scars, sinuses, pulsations 

Palpation:
Inspectory findings are confirmed 

Trachea - central

AP diameter 16 cm 

Transverse diameter 23 cm

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: 

Dull note on right mammary, interscapular infra axillary,  infrascapular

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard. Decreased breath sounds on right mammary, interscapular infra axillary, infrascapular

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :


        S1 and S2 heard. 



PER ABDOMEN:


Inspection :

       Umbilicus is central and inverted

       All quadrants are moving equally with respiration 

       No scars , sinuses , engorged veins, visible pulsations .

       Hernial orifices are free.

Palpitation :

       Abdomen is soft and non tender .

        No organomegaly.

Percussion :

       Tympanic note heard over the abdomen.

Auscultation:


       Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:on the day of presentation 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

27/1/2023 

On admission  pleural tap was done and 300 ml of pleural fluid was drained  
22/1/23

23/1/23
24/1/23

1300ml of pleural tap was drained on 3rd day of admission  post procedure chest x-ray 



26/1/23




16/07/2022


Serial ABG trends
SPUTUM AND PLEURAL FLUID CBNAAT WAS NEGATIVE

S - 

NO FEVER SPIKES 
C/O BREATHLESSNESS REDUCED


O-

PULSE -  76 bpm 

BP - 130/80 mmhg 

TEMP - 99 F  

CVS - S1 , S2 +

RS - BAE + , NVBS, DECREASED BREATH SOUNDS IN RIGHT INFRA AXILLARY AREA, INSPIRATORY CREPTS IN B/L ICA

PA - SOFT , NON TENDER

CNS - NAD

INPUT 1100 ML
OUTPUT 1050ML

CREAT- 4.4 (D1)- 4.5 - 5.3 - 4.0 - 4.3(D5)


A

RIGHT PLEURAL EFFUSION (SECONDARY TO TB) STAGE 5 CKD WITH LEFT HYDROURETERONEPHROSIS (10 MM CALCULUS AT LOWER POLE ) WITH ANEMIA OF CHRONIC DISEASE WITH DM -2 AND HTN (SINCE 4 YRS)

P

INJ AMOXYCLAV 1.2 GM IV/BD - D6


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