A 80 year old male patient with community acquired pneumonia

A 80 YEAR OLD MALE PATIENT PRESENTED  TO OPD WITH COMPLIANTS - SHORTNESS OF BREATH AND COUGH 

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A 80 year old male patient present to OPD with cheif complaints of shortness of breath and cough since 4 days.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 years back . And then he had chest pain which was radiating to the left arm for which he went to the hospital and after investigations as ecg findings show anterior wall myocardial infraction and right bundle branch block for which he underwent percutaneous transluminal coronary angioplasty in 2017. And was under medications T.ecospirin AV (70/20 )PO/OD  and T.met -XL 25 mg.since then he routine life was normal.

Then he complained of  lost of appetite and weight loss since 4 months and generalized weakness since 3months. H/o low backache since 3 months . Burning micturition since 3 months with frequency of 10-15 times in the night .Since 4 days he developed shortness of breath which is initially of grade 3 and progressed to grade 4 since last night associated with orthopnea and cough associated with sputum since 4 days and chills and rigors are present. Blood tinged sputum since admission. And pedal edema since 1week which is non pitting type. 

No chest pain , sweating , syncopal attack , palpitations , Giddiness.

HISTORY OF PAST ILLNESS

There is History of similar complaints 

History of cataract surgery B/L 6 months back

History of coronary artery disease in 2017 underwent PTCA .

PERSONAL HISTORY

Patient is vegetarian

Appetite - lost 

Bowel and bladder movements - irregular 

Micturition- abnormal

He was alcoholic from 25 years 90ml daily and stopped after undergoing PTCA.

He had habit of smoking since 25 years and stopped after PTCA.

GENERAL EXAMINATION

Patient is conscious , coherent , cooperative 

No fever spikes since admission

Pallor present

No icterus , cyanosis, clubbing, lymphadenopathy.

Pedal edema is present and it is non pitting type

Day1

Vitals :

Temperature-  afebrile

Pulse rate- 102bpm

Respiratory rate- 30cpm

Bp- 180/100mmHg

GRBS- 250mg/ dl

SYSTEMIC EXAMINATION

CVS-

Inspection- chest wall is bilaterally symmetrical

No precordial bulge

No visible pulsations , engorged veins , scars ,sinuses.

Palpation- JVP is not seen 

Auscultation- S1 ,S2 heard , no murmurs

RESPIRATORY EXAMINATION- position of trachea is normal , bilateral air entry +  , bilateral diffuse crepts heard in all areas .

PER ABDOMEN- soft and non- tender

CNS- patient is conscious

Speech is present

Reflexes are normal 

PROVISIONAL DAIGNOSIS

Community acquired pneumonia with cystitis with denovo DM2 with benign prostatic hyperplasia with CAD S/P PTCA.

INVESTIGATIONS

HEMOGRAM

Hb- 10.9%gm/dl

TLC- 12,100cells/ cumm

Neutrophils- 84%

Lymphocytes- 8%

Esonophils- 2%

Monocytes- 6%

Basophils-0%

RBC- 3.69million/ cumm

Platelet count - 2.20lakhs/ cu.mm

LIVER FUNCTION TEST:

Total bilirubin- 1.65mg/dl

Direct bilirubin- 0.46mg/dl

AST- 89IU/L

ALT- 15IU/L

Alkaline phosphatase- 890IU/L

Total proteins- 6.5gm/dl

ALBUMIN- 3.4gm/dl

RENAL FUNCTION TEST:

Creatinine- 0.7mg/dl

Urea- 23mg/dl

Ca+2 - 9.4mg/dl

UA- 2.7mg/dl

Phosphorus- 3.1mg/dl

Na+ : 132mEq/l

K+ :3.3mEq/l

Cl-  : 86mEq/l

ABG:

Ph:7.40

PCO2 :24.7mmHg

PO2: 64.5mmHg

HCO3- : 17.9mmol/l

CHCO3 : 15.2mmol/l

LIPID PROFILE:

Cholesterol- 153mg/dl

HDL-36mg/dl

LDL-99mg/dl

VLDL- 11mg/dl

20/12/21

TREATMENT:

Inj- Augmentin 1.2gm IV/ BD

Tab. Nicardia 20mg PO/ stat

Tab. Lasix 40mg PO/BD

Tab. Ecospirin AV (75/20) PO/DO

Tab. Met- XL 25mg PO/OD

Syrup - Ascoril -D 15ml PO/TID

NEB with budecort - 12th hourly , ipravent and Duolingo -6th hourly.

Inj- actrapid s/c acc to sliding scale

BIPAP INTERMITTENTLY

BP monitoring 2nd hourly

Tab.Azithromycin- 500mg PO/OD

Inj. Hydrocortisone 100mg

Inj . Deriphyline 2cc IV /stat

Inj . Tramadol 100ml NSIV / OD.

Day 2 

S - cough with sputum production , cold, sob decreased a bit compared to day 1  , one fever spike present .

O- patient is conscious, coherent, oriented to time place and person. 

Temp- 99°f

Pulse rate-96bpm

Respiratory rate-22cpm

Bp- 120/70mmHg

SpO2 - 96% with 10lits of O2 

Grbs- 111mg/dl

Respiratory examination- bilateral air entry+, B/l inspiratory crepts + at scapular , infrascapular region.

Cvs- s1s2 +

PA - soft , contender, bowel sounds heard

Cns- no focal neurological defecit.

A- community acquired pneumonia , pulmonary kochs, h/o coronary artery disease ( post PTCA 2017), denove DM2, grade 1 prostomegaly.

P- to collect sputum ang report

-Inj AUGMENTIN 1.2 gm iv bd

Tab azithromycin 500mg po od

Neb with ipravent 6th hourly , Budecort 8th hourly , mucomist 8th hourly.

Syrup ASCORYL 10ml po tid

Tab ecospirin av (75/20) po hs

Tab metxl 25mg po.od

-Inj hai SC tid 

-ivf 1NS 1RL 50ml/hr