80 year old male with SOB,PAST CAD AND ?CAP


80 yr old came to casualty with chief complaints of SOB since 4 days 

HOPI 

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YEARS BACK THEN HE HAD CHEST PAIN 

ECG FINDINGS SHOW ANTERIOR WALL MI AND RIGHT BUNDLE BRANCH BLOCK 

CABG AND STUNTING WAS DONE IN 2017 

H/O WEIGHT LOSS SINCE 4 MONTHS 

H/O LOSS OF APPETITE SINCE 4 MONTHS 

NO H/O RENAL CALCULI 


SINCE THEN PATIENT WAS ON TAB .ECOSPORIN AV 70/20 PO/OD 

TAB.MET XL 25 MG PO/OD 

SINCE 3 MONTHS BURNING MICTURITION , POLYURIA, INCREASED URINARY FREQUENCY 

?BOWEL AND BLADDER INCONTINENCE 

GENERALIZED WEAKNESS SINCE 3 MONTHS 

SOB SINCE 4 DAYS  INITIALLY GRADE 3 PROGRESSED TO GRADE 4 

SINCE LAST NIGHT ASSOCIATED WITH ORTHOPNEA 

COUGH ASSOCIATED WITH SPUTUM ,CHILLS AND RIGOR 

NO CHEST PAIN, SWEATING,SYNCOPAL ATTACK , PALPITATIONS,GIDDINESS 

H/O SIMILAR COMPLAINTS IN THE PAST 

H/O BURNING MICTURITION 4 MONTHS BACK 

TREATED CONSERVATIVELY 

TREATMENT HISTORY 

DENOVO DM 

H/O CATARACT SURGERY B/L 6 MONTHS BACK 

CAD IN 2017 

PHYSICAL EXAMINATION

PERSONAL HISTORY 

Marital status - married 

Appetite - lost 

Diet - Mixed 

B AND B - IRREGULAR 



GENERAL EXAMINATION :

Patient is conscious , coherant, cooperative 

 No pallor, icterus , cyanosis , lymphadenopathy, edema .

                                                                                             



INVESTIGATIONS 








                                                                                                       










       












                              


VITALS

BP : 180/100 MM HG

PR : 102BP MIN

RR : 30/ MIN

SPO2: 70  percentage on RA

TEMPERATURE - AFEBRILE 

GRBS - 250 mg/dl 




SYSTEMIC EXAMINATION

CVS : S1, S2 +,no murmurs 

RS : BAE + , B/L DIFFUSE  HEARD IN ALL AREAS 

P/A : soft , nontender 

CNS : NAD 



TREATMENT 

1 Injection Augmentin 1.2 g IV/BD 

2 Tab NICARDIA 20 MG PO/STAT 

3 TAB ECOSPORIN -AV (70/20) PO/OD 

4 MET XL 25 MG PO/OD 

5 TAB LASIX 40 MG PO/OD (IF SBP>110  MM OF HG )

6 NEB WITH BUDECORT 12 HRLY ,IPRAVENT 6 HRLY 

7 SYP ASCORIL -D PO/TID 15ML -15 ML-15 ML 

8 INJ ACTRAPID S/C ALL TO SLIDING SCALE 

9 BIPAP INTERMITTENTLY 

10 GRBS 70 PROFILE 8AM-19 AM-2 PM -4 PM-8 PM-10 PM-2 AM 

11 BP MONITORING 2 ND HOURLY 

12 I/O STRICTLY 


SOAP NOTES DAY 1



S - cough with sputum production, cold, sob decreased a bit compared to yesterday, one fever spike present yesterday at 6pm


O- Pt conscious, coherent, oriented to time place person

Temp -99f

Bp- 120/70mmhg

PR- 96bpm

RR- 22cpm

Spo2- 96% with 10lit o2


Grbs-111mg/dl

I/o-800/1200ml


Rs - bae +, b/l inspiratory crepts + at scapular, infrascapular region

Cvs- s1s2+

P/a - soft, non tender, bs+

Cns - no focal neurological defecit 


A-

? Community accquired pneumonia

? Pulmonary kochs 

H/o Coronary artery disease ( post ptca 2017)

Denovo t2dm

Grade 1 prostatomegaly


P- to collect sputum afb report


Inj Augmentin 1.2gm iv bd

Tab azithromycin 500mg po od 

Neb with ipravent 6th hrly, budecort8th hrly, mucomist 8th hrly

Syp ascoril 10ml po tid

Tab ecospirin av (75/20) po hs

Tab metxl 25mg po od

Inj hai SC tid after informing grbs

Ivf 1NS 1RL @ 50ml/hr


SOAP NOTES DAY 2



22 


S - cough with sputum production, cold, sob decreased a bit compared to yesterday,no fever spikes since yesterday


O- Pt conscious, coherent, oriented to time place person

Temp -99f

Bp- 110/70mmhg

PR- 102bpm

RR- 22cpm

Spo2- 96% with 8lit o2


Rs - bae +, b/l inspiratory crepts + at scapular, infrascapular region

Cvs- s1s2+

P/a - soft, non tender, bs+, didn’t pass stool since 2days, passing flatus

Cns - no focal neurological defecit 


A-

? Community accquired pneumonia

? Pulmonary kochs 

H/o Coronary artery disease ( post ptca 2017)

Denovo t2dm

Grade 1 prostatomegaly


Sputum for afb - negative

P-to send sputum for cbnaat


Inj Augmentin 1.2gm iv bd D3

Tab azithromycin 500mg po od D3

Neb with ipravent 6th hrly, budecort8th hrly, mucomist 8th hrly

BIPAP intermittently

Syp ascoril 10ml po tid

Tab ecospirin av (75/20) po hs

Tab metxl 25mg po od

Inj hai SC tid after informing grbs

Ivf 1NS 1RL @ 50ml/hr



SOAP NOTES DAY 3



23/12/21


S - cough with sputum production, sob decreased a bit compared to yesterday,no fever spikes since yesterday


O- Pt conscious, coherent, oriented to time place person

Temp -99f

Bp- 110/70mmhg

PR- 102bpm

RR- 22cpm

Spo2- 96% with 8lit o2


Rs - bae +, b/l inspiratory crepts + at scapular, infrascapular region

Cvs- s1s2+

P/a - soft, non tender, bs+, didn’t pass stool since 3days, passing flatus

Cns - no focal neurological defecit 


A-

Community accquired pneumonia

? Pulmonary kochs 

H/o Coronary artery disease ( post ptca 2017)

Denovo t2dm

Grade 1 prostatomegaly


P-

Inj Piptaz 4.5gm iv tid d2

Tab azithromycin 500mg po od D3

Neb with ipravent 6th hrly, budecort8th hrly, mucomist 8th hrly

BIPAP intermittently

Syp ascoril 10ml po tid

Tab ecospirin av (75/20) po hs

Tab metxl 25mg po od

Inj hai SC tid after informing grbs

Ivf 1NS 1RL @ 50ml/hr




PROVISIONAL DIAGNOSIS

Community acquired pneumonia with cystitis with COPD with denovo DM2 with BPH with CAD S/P PTCA(2017)


Comments

Post a Comment

Popular posts from this blog

30 year old RENAL TRANSPLANT RECIPIENT with deranged RFT

Image
 Chief complaints  Renal transplant recipient came with deranged RFT values on routine investigation done for his renal transplant came to kamineni on 7/2/22 No c/o pedal odema  No c/o SOB ,facial puffiness  HOPI  Patient was apparently asymptomatic then on routine investigation done for renal transplantation revealed elevated creat levels  Sr creat - 3.5mg/dl  Urea - 85 mg/dl  No h/o decreased urine output ,urinary retention Past history  H/o previous admissions for dialysis for 2 years (CRF)  K/c/o HTN on tab amlong 10 mg - 5 mg - 10 mg  Tab.arkamime 0.2 mg po/tid  H/o 2 times intubation and extubation i/v/o pulmonary oedema , hypertensive emergency and resistant hypertension 2 years back  H/o loculated pleural effusion and icd drainage 2 years back  Treatment history  K/c/o htn on tab amlong and arkamine  Surgical history  K/c/o renal transplant recipient  Personal history  Single  Appetite - normal  Bowel and bladder movement - normal  No known addictions  Family history - not sign
Read more

50 yr old farmer with decreased urine output

Image
Chief complaints  C/o SOB since 1 week  C/o swelling in the legs  C/o decreased urine output  HOPI A 50 yr old Farmer doing his regular work, of driving tractor till one week ago when he had sob with sweating, taken to a doctor outside ,where his grbs was recorded low ,was revived with eating a chocolate only, but he continued to take his oha even after that,rft showed increased creatinine,since 3 days his symptoms aggrevated and was brought here for further management ,2 sessions of dialysis  1 st -19/2/22 from 10 am to 2 pm , 2 nd - 20/2/22 were done   PAST HISTORY  known case of DM since 3 years on medication  HTN since 6 months (giddiness first symptom ) NO H/o asthma ;TB;EPILEPSY PERSONAL HISTORY  Marital status - married  Occupation - Farmer  Appetite - Normal  Diet - Decreased appetite  Bowel and bladder movements - regular Addictions -  Chronic alcoholic since 20 years daily 180 ml. Chronic smoker since 20 years  daily 2-4 beedis per day. No significant family
Read more

44 year old with ALD

Image
  CHIEF COMPLAINTS   44 year old male came to casualty with chief complaints of fever with chills on and off high grade associated with chills and rigor  HOPI  patient was apparently asymptomatic 12 years back had history of intake of alcohol initially 90 ml   gradually progress to amount of 200 ml  since 2 years patient was on alcohol 200 ml , quantity increased to daily intake  of with no  or minimal food intake H/O agressive behaviour  tremors +  decreased appetite  yellowish discoloration of sclera present  vomiting of 1 episode , patient was admitted in outside hospital and treated as alcoholic liver disease With TB - 23.7 gradually reduced to 2.5   pain abdomen +  passing stools (1-2 ) episodes/day  No loose stools , vomitings,malena ,blood in stools  Past history  N/K/C/O - DM, ASTHMA,TB , EPILEPSY Personal history  married  appetite - lost  bowel - regular  micturition - normal  known alcoholic since 12 years  GENERAL EXAMINATION  no pallor,icterus,cyano
Read more