General medicine case 3

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Date of admission: 19- 09-21

A 90year old male presented to OPD with chief complaint of hemoptysis since 2 days (2 episodes) 

 History of present illness:

- patient was apparently asymptomatic  2 days ago later  he had cough as with blood tinged sputum-small quantity .

- H/O similar complaints for the first time 20 yrs back and 10 months back

from then on and off for every 6- 8 months 

- Not on any medication 

History of past illness:

60 yrs back- He had a H/O trauma (accident) to liver ,got admitted in hospital and got operated 

40 yrs back- He had H/O trauma to right side of his shoulder and got operated conservatively 

20 yrs back- He had H/O of trauma to his front side of right leg-femur fracture and got operated

14 years back he had history of trauma to his left eye for which he went through eye surgery(enucleation) in hospital and his eye got removed 

No history of asthma , epilepsy, TB , CAD, DM, HTN 

Personal  history:

Diet: mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder movements : Regular 

20yrs back he stopped alcohol and smoking

Family history: 

No similar complaints in family

General examination: 

Patient is conscious, coherent, cooperative, well oriented 

 No pallor , icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

Vitals-

Temp: 95 °f 

PR: 78/min

RR: 20/min

BP: 110/70mmHg

SPO2: 98%

GRBS: 108mg/ dl

Systemic examination:

-CVS: 

S1,S2 heard

Apex beta 5th ICS 

No thrills

No cardiac murmurs

-Respiratory system :

Position of trachea is central

Bilateral air entry is normal 

Normal vesicular breath sounds  heard 

No added sounds 

-Per abdomen:

Abdomen is not tender 

Bowel sounds heard 

No palpable mass or free fluid 

-CNS 

Patient is conscious 

Speech is present 

No focal deficit 

No meningeal signs 

Glasgow scale- 15/15 

Provisional Diagnosis: 

-Acute bronchitis 

-Hematemesis

-Hemoptysis

Investigation:

- Complete blood picture: 

Hemoglobin- 12.5 gm/dl

TLC: 15,800cells/cumm

Neutrophils: 75%

Lymphocytes: 14%

Eosinophils: 05%

Monocytes: 06%

Platelet count : 2.33 lakhs/cu.mm 

Smear: Normocytic normochromic with leucocytosis

Prothrombin time

APTT

Bleeding and clotting time 

Blood grouping

CUE 

CT-scan of chest 

Treatment:

 

Day 1

-IVF: NS/RL- 100ml/hr

-Inj TRANEXA 500mg/ IV BD

-Neb with duolin 6th hourly and Budecort 12th hourly 

- syp ASCORYL

-w/f bleeding manifestations

- tab . AUGMENTIN 625mg po/ tid 

- tab . PANTOP 40mg po/od 

Day 2 

-IVF NS/RL- 100ml/hr

- -inj TRANEXA 500mg /IV BD 

-Neb with duolin 6th hourly and Budecort 12th hourly 

- syp  Grillnictus 15ml po/tid

- tab. AUGMENTIN 625mg po/tid

- tab. PANTOP 40mg po/od

- monitor vitals - 2nd hourly 

- what are the causes of acute bronchitis?

- how it is diagnosed?

-  are there complications associated with bronchitis?

- does his previous trauma treatment  history's could cause bronchitis? 

- does it occur with any withdrawal symptoms of alcohol or smoking?