75 year old male



A 75 year old male patient came to casualty with the complaints of fever  and cough since four days 

Patient was apparently asymptomatic one week ago. Then , he developed pain abdomen ( generalised ) since 1 week , not associated with vomitings and difficulty in passing stools. He developed fever since 4 days which was high grade associated with chills and cough since 4 days associated with expectoration.
H/O orthopnea present , H/O dribbling of urine .
No H/O pedal edema, PND
K/C/O DM and on OHAs 
K/C/O HTN
He is a known alcoholic and last intake was 15 days back.

General examination:
The patient is conscious coherent and cooperative
Moderately built and moderately nourished. 
Vitals:
Temp: afebrile, PR 120bpm, RR 22 cpm, BP 110/60mm Hg , GRBS 208 mg%

P/A: 
Shape of abdomen: scaphoid
Non tender
Liver and spleen - not palpable
Bowel sounds are present

CVS: S1, S2 +
RS: BAE + , NVBS +
CNS: NFND

Investigations:

8 /9 /10



ECG on. 7/9/21
ECG on 8 /9/21

 
Chest x ray : 
X ray of both hands ,elbow , ankle joints:





USG abdomen:

Treatment given : 

1)IVF 0.9 % NS  AND RL @ 50 ML / HR
2) ORAL FLUIDS 
3) INJ AUGMENTIN 1.2 G/ IV/ BD
4)INJ  PAN 40 MG / IV/OD
5) SYP AMBROXOL 10 ML / PO/ TID
6)INJ HAI S/C / TID
7) INJ OPTINEURON 1 AMP IN 100 ML NS /IV/OD
8)TAB PCM 650 MG / PO/TID
9) INJ NEOMOL 1G/IV/SOS
10) NEB WITH BUDECORT , MUCOMIST @ 4 HOURLY
11) SYP CREMAFFIN PLUS 10 ML / PO / H/S


Provisional diagnosis:
Septic shock secondary to pneumonia ( bacterial > viral) ( Right lower lobe consolidation)

Comments

Post a Comment

Popular posts from this blog

42 year old women with multiple health events

Image
I have given this case to solve and understand about " Patient clinical analysis " With given history and provided clinical investigations.  Clinical problems in patient: Migraine Kidney dysfunction - oligouria Swelling Sleep disturbances Left hand numbness Poor vision Broken leg Autism Intolerance to some kind of food Reasons for problems: From given data it could be from G 6 PD deficiency and AMPD 1 deficiency Sleep deprivation is due reduce synthesis of amino acids like adenosine defiency which is inhibitory to brain.  Kidney dysfunction is due to decrease in atp synthesis which also explains increase in intake of salt Swelling is due to g6pd defiency Others symtoms are due to genetic abnormalties like: Seattle type G6PD deficiency AMPD1 - AMPD1 deficiency heterozygous MTHFR - homozygous for C677T of MTHFR = 10-20% efficiency in processing folic acid = high homocysteine, low B12 and folate levels WNK1 mutation HLA-DRA - 3x higher risk for developing a peanut allergy In pop
Read more

56 year old male

A 56yr old male came to casuality with  chief  complaints of  pain abdomen since 5 days polyuria since 5 days  Dyspepsia since 2 days  History of present illness:  patient was apparently asymptomatic 5 days back,then he developed pain in the abdomen (Epigastric region) non radiating,not associated with nausea,vomitings(burning type of pain) decreased on using medication  H/o alcohol binge 5 days back,then developed pain abdomen ( diffuse type, squeezinf type of pain) not associated with nausea,vomitings)  went to a local RMP and diagonsed with Diabetes mellitus (DE NOVO) and was started on (T.GLIBENCLAMIDE and METFORMIN)/PO/OD No H/O burning micturition,fever,cough,cold,SOB,tingling sensation of B/L UL and LL,loose stools and chest pain Past History : H/O simliar complaints in the past diagnosed as pancreatitis  not a K/c/o DM,HTN  k/c/o Alcoholic since 30 yrs  last intake (3-5 days back) he is a smoker ( stopped 8 years back ) Personal history: mixed diet normal appetite bowel regular
Read more

16010086 long case

Image
This is an 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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 on the comment 29 year old male who is a daily wage labourer resident of Nalgonda, came to hospital with   chief complaints on & off fever since 2 yrs , shortness of breath , b/l pedal edema , abdominal distension and decreased urine output since 1 year History of present illness : Patient was apparently asymptomatic 2years ago and then one day he developed  fever  (high grade , continuous , associated with chills & rigors) and  generalized body aches  for which he went to a local RMP and he pr
Read more