GENERAL MEDICINE-ELOG
September 27,2022
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40 YEAR OLD MALE WITH SOB
40 year old male patient,resident of pothunuru came to casualty at night on 25/09/2022 with chief complaints of
-Fever since morning
-SOB grade 4 (MMRC) since evening
History of present illness-
He is farmer by occupation.
Patient was apparently asymptomatic 20 years back.
Then developped B/L pedal edema(patient says truck tire has passed on his left leg and stone has fallen on his right leg)from then he started developping pedal edema(upto knee,pitting type) on and off.Not on any medication since 20 years.
pedal edema aggravates on sitting for longer duration and taking rest.relieves on walking for sometime
From 4days he was having decreased urine output and burning micturition
Yesterday night he consumed alcohol and next day he went to work at 9am.Returned to home for lunch at 1pm and went to work again
In the evening he developped fever(high grade) associated with chills and rigors
He started developping breathlessness while working and went home.By night it slowly progresses to grade 4(mmrc).orthopnea present
Past history-
N/K/C/O-HTN,DM,TB,Asthma,Thyroid disorders,epilepsy
Family history-
No similar complaints seen in family members
Personal history-
Appetite-normal
Sleep-adequate
Diet-mixed
Bowel Movements-regular
Bladder movenents-decreased urine output and burning micturition since 4 days
Alcohol-Drinks from past 20 years(100ml per week)
Tobacco chewing since 10 years(occasionally)
General examination
Pallor-
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-B/L peda edema (upto knee,pitting type) on and off since 20 years
Vitals-
BP-100/70 mmHg
PR-114bpm
RR-38cpm
SPO2-88% at RA
GRBS-122 mg/dl
TEMP-102.5°F
Systemic examination
=>CVS-S1S2+
No thrills
No murmurs
=>R/S-BAE+
-Decreased breath sounds in b/l infrascapular areas
-crepitations present in b/l infrascapular areas
-trachea central
-no wheeze
-orthopnea present
=>P/A-shape obese
-soft and non tender
-no organomegaly
=>CNS-patient is conscious coherent and cooperative
-speech normal
-no signs of meningeal irritation
-cranial nerves intact
-NFND
Provisional diagnosis-
LRTI WITH RIGHT LOWERLOBE CONSOLIDATION
AKI
Investigations-
25/09/2022
26/09/2022
27/09/2022
Treatment-
1)INJ.DOXY 100MG/IV/BD
2)INJ.AUGMENTIN 1.2GM/IV/BD
3)INJ.LASIX 20MG/IV/BD
4)IVF NS @50 ML/HR
5)INJ.THIAMINE (200MG IN 100ML NS)OVER
MIN/BD
6)INJ.OPTINEURON 1 AMPULE IN 100ML NS
OVER 30 MIN /OD
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