CBBLE UDHC SIMILAR CASES
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
HOPI:
PT WAS AA 3 DAYS BACK THEN HE PRESENTED WITH SOB SINCE 3 DAYS [MMRC GR-II] , INCREASED ON EXERTION AND RELIEVED ON REST
NO ORTHOPNEA , NO PND AND NOT ASSOCIATED WITH WHEEZE
C/O FEVER SINCE 3 DAYS, LOW GRADE, INTERMITTENT AND NOT ASSOCIATED WITH CHILLS AND RIGOR , SWEATING AND NOT ASSOCIATED WITH DIURNAL VARIATION
LOSS OF APPETITE +
NO H/O COUGH,CHEST PAIN, CHEST TIGHTNESS ,HEMOPTYSIS,LOSS OF WEIGHT.
PAST H/O:
H/O SIMILAR COMPLAINTS IN THE PAST 2YRS AGO FOR WHICH SHE WAS ADMITTED AND POST DISCHARGE NEBULIZATION ,
K/C/O DM-2 SINCE 8Y AND ON MEDICATION
H/O BIOMASS EXPOSURE + FOR 40 YRS
NOT K/C/O HTN, BA,CAD,THYROID, TB.
NO H/O COVID
PERSONAL H/O:
HOMEMAKER BY OCCUPATION
DIET - MIXED,
APPETITE -DECREASED
BOWEL MOVEMENT - REGULAR
BLADDER MOVEMENTS - NORMAL
NO ADDICTIONS
NO KNOWN DRUG ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
ON EXAMINATION
PATIENT IS CONSCIOUS , COHERENT, COOPERATIVE , THIN BUILT AND MODERATELY NOURISHED
NO SIGNS OF PALLOR ,ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, PEDAL EDEMA.
VITALS:
TEMP: AFEBRILE
PR: 110 BPM
BP:130/70 MMHG
SPO2: 84% ON RA
GRBS: 95mg%
RR: 25CPM
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD, NO MURMURS HEARD
PER ABDOMEN: SOFT, NONTENDER
CNS : NAD
RESPIRATORY SYSTEM :
INSPECTION: SHAPE OF THE CHEST- ELLIPTICAL
B/L SYMMETRICAL CHEST
TRACHEA APPEARS TO BE CENTRAL
EXPANSION OF CEHST : EQUAL ON BOTH SIDES
ACCESSORY MUSCLES REPIRATION +
NO DROPPNG OF SHOULDER
NO CROWDING OF RIBS
WASTING OF MUSCLES +
SPINOSCAPULAR DISTANCE EQUAL ON BOTH SIDES
PALPATION:
ALL INSPECTORY FINDINGS CONFIRMED
NO LOCLAL RISE OF TEMPERATURE
NO TENDERNESS
TRACHEA SLIGHTLY DVIATED TO RIGHT
CHEST MOVEMENTS EQUAL ON BOTH SIDES
AEPX BEAT @ LEFT 5TH ICS MEDIAL TO MIDCLAVICULAR LINE
TVF EQUAL IN BOTH AREAS
PERCUSSION:
DIRECT: RESONANT
INDIRECT:RESONANT
AUSCULTATION:
BAE+
VBS: HEARD
CREPTS + @ RIGHT INFRA SA , IAA
INVESTIGATIONS
2D ECHO
FBS 83
PLBS
CXR
HRCT CHEST
Multiple focal area of bronchiectatic changes seen in both lung mainly in apical segment of left upper lobe ,right middle lobe ,lingular segment and left lower lobe with few area of mucoid impaction.
Multiple centrilobular nodules in both lung mainly in right middle lobe and left lower lobe.
Above features are suggestive of infective bronchiolitis likely secondary to Koch's disease.
DIAGNOSIS :- ACUTE EXACERBATION OF BRONCHIECTASIS WITH TYPE 2 DM
TREATMENT GIVEN :-
1]INJ.AUGMENTIN 1.2 G /IV/TID
2]INJ.PAN 40MG OD [BBF]
3]INJ.HYDROCORT 100MG IV OD
4]O2 INHALATION WITH NASAL PRONGS @ 2-3L/MIN
5]NEB BUDECORT TID ; MUCOMIST 4TH HRLY
6]T.MUCINAC LC/HS/TID
7]TAB.MONTAC LC HS/OD
8]SYP.ASCORIL 2 TSP TID X 1 WEEK
9]TAB.PCM 650MG SOS
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