80 yr old male with right lung collapse

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 80 year old male patient was brought to casualty(i.e 4/10/2022)

Chief complaints:

Shortness of breath since 4days

Fever since 4days

Cough since 3days

Loose stools 2days

History of present illness:

Patient was apparently symptomatic 1 month back then he developed anuria for which he was admitted in a hospital for a day foleys was placed and medication was given for 10 days ,then patient developed shortness of breath four days back which was insidious in onset gradually progressed from grade 2 to grade 4 (mmrc),no postural variation ,no history of suggestive of paroxysmal nocturnal dyspnoea, chest pain ,associated with cold and cough ,cough was productive, sputum mucoid,whitish,copious and not blood tinged and has a history of fever which was intermittent ,on and off ,no diurnal variation and associated with loose stools and burning micturition ,loose stools since two days 3 to 4 episodes per day ,non-bulky not associated with pain abdomen ,non-bloodstained .

This developed after drinking beer(2bottles)

Past history:

No similar complaints in the past

Not a known case of DM,ASTHMA,HTN,EPILEPSY,TB

30 years back, when he developed a swelling on the right lower chest , pasaramandhu was used after which the patient is tilted to right side.

Personal history:

Diet:mixed

Appetite:normal

Bowel and bladder movements:irregular (loose stools), decreased urine output since 1month

Addictions: alcohol consumption from past 30years (daily quarter) stopped 1 month back , last intake was 5 days back

 Smoking (Chutta) daily 4-5 , stopped 5 years back

No known allergies 

Family history:

No relevant family history

General Examination:

Patient was not C/C/C not oriented to time,place and person

Pallor -absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

Vitals:

PR:87bpm

BP:140/70mm Hg

RR:35cpm

Spo2:94%

RBS: 228 mg/dl

Systemic examination:

RS:

Inspection :

                                          R. L

Supraclavicular area :hollow. Normal

Infraclavicular area. :Crowding Normal

Position of trachea :prominent SCM on rigth side

Position of Apex beat :5 th ics

Chest : asymmetry

Increased AP diameter on left side

Palpation:

Confirmed inspiratory findings.

Trachea is deviated to right 

Lung expansion is less on right side.

Percussion:

Auscultation :

Decreased air entry on rigth side

Normal vesicular breath sounds 

CVS:

Apex beat at 5th ics at midclavicular line

 S1,S2 heard

Per abdomen: 

Scaphoid

Scar + rt side( h/o? hernia sx)

No Tenderness 

No organomegaly 

CNS:

Involuntary movements (? Fasiculations + at rt and lt proximal lowerlimb)

Tone : normal in all limbs

Reflexes: 

           Rt. Lt.

  B. +++ ++

  T. ++ +

  K. ++ ++

  A. ++ ++    

  P. Mute

   

Intially pulmonology consultation done : 

Suggested Bipap with peep 5 and fiO2 0.3

Investigations:

Provisional diagnosis:

Altered sensorium (hypoactive) secondary to type 2 respiratory failure,?uremic encephalopathy Non oliguric aki with rt upper lobe fibrosis(?TB)

Treatment:(4/10/22)

1. IV fluids -NS,RL 

2.nebulization with milk and salbutamol

3. 25D with 10units HAI inj stat

4. Watch for hypoglycemia

5.inj lasix 40mg iv stat

6. 25D infusion /10ml/hr until 150ml /dl

7. Hourly GRBS monitoring

8. Monitor vitals hrly charting

9.strict i/o charting

10.syp. grillinctus 15ml/oral/BD