A 35Years Male with c/o dry cough,SOB grade ll,nausea and with h/o hemoptysis

A 35 years Male with c/o dry cough,SOB grade ll,nausea and with h/o hemoptysis

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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

A 35 year male, driver by occupation, came with complaints of dry cough, grade II sob, nausea and with h/o hemoptysis.

History of presenting illness: 

A 35 year male with h/o dry cough, episode of hemoptysis, low grade fever, grade II sob (17/3/22), 

was admitted at yashodha hospital on 17/3/22 and diagnosed as:

- AKI on CKD - was dialysed 4times and advised for maintenance HD.

- LRTI - B/L non homogeneous opacities on xray - edema with superadded infections (on HRCT chest).

- Sepsis MODS.

then patient was discharged on 28/3/22.

CREATININE- 11   @admission

                          - 9   @discharge

USG - grade II RPD, CMD near complete lost, 

          - size - 9X3cm (Right)

                     - 8X3cm (Left)

2D ECHO- LV RWMA, EF:42%

Pt was asked to come for review after 1 week but pt didn't do due to personal reasons and came here for MHD.

presently c/o dry cough +, SOB grade II, Nausea +,

 hemoptysis  subsided.

No c/o reduced urine output, pedal edema , facial puffiness.

OUTSIDE INVESTIGATIONS: 

S.C3 AND C4 - NORMAL, 

ANTI GBM - NEGATIVE

ANCA - C, P-ANCA - NEGATIVE

CUE: ALB 3+, 24HR PROTEIN - 1.26gms, RBC - 15-20/hpt

ANA - NEGATIVE,  RENAL BIOPSY L.M Chronic tubulointerstitial inflammation.

comorbidities- Denovo HTN ( diagnosed 20days ago), non DM,  non CAD.

BAL fluid - 

AFB - NEGATIVE, 

C/S - No growth, 

fungal c/s - candidia albicans sensitive to voriconazole, flucanozole, capsi fungin , micofungi

PAN fungal DNA - POSITIVE

DNA QUALITATIVE:

Aspergillus niger - low positive

Aspergillus fumigatus, flavus - negative

Aspergillus mucoralesps - negative

Mycobacterium - negative

PAST HISTORY:

N/k/c/o DM , BA, EPILEPSY.

PERSONAL HISTORY:

HABITS: OCCASIONAL TOBACCO USE

He follows a mixed diet. 

Appetite -Normal,

Bladder movements- normal 

Bowel movements- Normal . 

Sleep- Adequate.

FAMILY HISTORY: No significant family history.

GENERAL EXAMINATION : 

patient is conscious ,coherrent, co operative and well oriented to surroundings. He is moderately built and nourished. 

Mild Pallor ,no cyanosis, no icterus, no lymphadenopathy. 

Vitals:

Temperature: 99.8

Pulse rate: 112 beats / min.

 Respiratory rate: 36 cycles / min.

 Bp: 220/140 mmhg

Spo2: 94@RA

Grbs: 104mg/dl

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.

RS: BAE+, B/L crepts +

P/A: Soft, Non-tender

CNS: NAD

INVESTIGATIONS:

(8/4/22)

RBS-90MG/DL

HB-9.8

TLC-11,500 (87%N)

PLT-2.67

CUE: ALB - +, SUGARS - NIL, RBC - NIL

ABG: PH: 7.32, PO2: 79.1, PCO2: 13.6, HCO3: 6.9, ST.HCO3: 11.4, O2 sat: 93.5.

LFT: TB-2.44,DB - 0.56, AST -13, ALT- 10, ALP- 236, T.P- 6.2, ALB- 3.42, A/G: 1.23.

RFT- UREA: 182, CREAT: 8.7, URIC ACID: 9.4, Ca: 9.9, PO4: 7.2, Na: 139, k: 4.5, cl: 105.

SEROLOGY: NEGATIVE.

(9/4/22)

HB-9.6

TLC-8,800 (78%N)

PLT-2.55

ABG: PH: 7.49, PO2: 73.1, PCO2: 29.5, HCO3: 22.7, ST.HCO3: 24.3, O2 sat: 94.6.

LFT: TB-2.90, DB - 0.63, AST -12, ALT- 9, ALP- 221, T.P- 5.9, ALB- 3.51, A/G: 1.15.

RFT- UREA: 125, CREAT: 6.2, URIC ACID: 6.3, Ca: 9.9, PO4: 5.5, Na: 144, k: 3.7, cl: 103.

(10/3/22)

HB- 10.3

TLC- 12,000 (78% N)

PLT- 2.94 

RFT- UREA: 151, CREAT: 7.5, URIC ACID: 7.6, Ca:8.0, Po4: 7.0, Na: 140, k: 4.0, cl: 9.8

ABS EOSINOPHIL COUNT: 240

(11/3/22)

HB: 9.6

TLC: 10,300 (83%N)

PLT: 2.78

RFT- UREA: 91  CREAT: 5.1  URIC ACID: 4.6  Ca: 10  Po4: 4.9   Na: 146  k: 3.9  cl: 97

FERRITIN- 889.7 ng/ml

(12/3/22)

HB: 9.7

TLC: 11,000 

PLT:  2.97

RFT- UREA:133  CREAT:6.4  Na: 140  k: 3.9  cl: 97

SR.IRON: 79

DIAGNOSIS: 

CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)

? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)

? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)

 TYPE 1 RESPIRATORY FAILURE, HTN +

TREATMENT:

1) INJECTION LASIX 40 MG IV TID TAB.

2)TAB. PAN 40MG PO/OD 

3)TAB. ZOFER 4 MG PO/BD 

4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD

6)SYRUP GRILLINCTUS 10 ML PO/TID

7)TAB.MONTEK -LC PO /BD

8)INJ. EPO 4000IU S.C WEEKLY ONCE

9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 

10) T.NICARDIA 20MG PO BD

11) T.ARKAMINE 0.1MG PO BD

12)TAB.CARDIVAS 3.125MG PO /BD

13)TAB.ECOSPRIN-AV 75/20MG PO/HS

14)I/O CHARTING,TEMP CHARTING

15)TAB.DOLO 650 MG PO/SOS (IF FEVER )

16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F