65 yr old male with fever,dry cough and generalised weakness

 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.


CASE PRESENTATION:


A 65 year old male came to casualty  with c/o

Fever since 20 days 

Cough since 10 days

Generalised weakness since 10 days

HOPI:

Patient was apparently asymptomatic 20 days back then he developed fever which is  of high grade,intermittent,  associated with chills and no diurnal variation. 

He  had Cough since 10 days which is associated with sputum which is white in colour

He also had loss of appetite and generalised weakness

No h/o nausea, vomiting 

No h/o loose stools

No h/o constipation 


PAST HISTORY:

K/C/O TB 1 year back(used medication for 6 months)

Not a K/C/O DM/HTN


Personal History :

Diet : mixed
Appetite : Decreased
Sleep : Disturbed 
Bowel movements : Normal 
Bladder movements : Normal 

On Examination :

Patient is conscious, coherent and cooperative.
Pallor -Absent
Icterus -Absent
Cyanosis -Absent
Clubbing -Absent
Lymphadenopathy -Absent
Edema -Absent


























VITALS :
AT THE TIME OF ADMISSION :
TEMP. : 103.2 F
PR : 90 BPM
RR : 18 CPM
BP : 130/70 MM HG
SpO2 (on Room air) : 98%
GRBS:114 GM/DL


On Systemic Examination:

CVS : S1, S2 heard
RS : BAE present
P/A : soft, Non tender
CNS : HMF Intact

Investigations :

On  21/10/22




















Usg on 10/10/22


2D ECHO



On 23/10/22

Hb-6.8
TLC-18,000
Plt-5.0
Urea-70
Creatinine-2.8
Na+ - 135
K+ - 4.2
Cl-   - 106




On 24/10/22

Hb-6.5
TLC-13000
PCV-20.1
RBC-2.31
Pt count-5.50

On 25/10/22












PROVISIONAL DIAGNOSIS:? VIRAL PNEUMONIA  WITH AKI ON CKD


TREATMENT:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.IV FLUIDS NS@ UO + 30 ML/HR

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.INJ.PAN 40 MG/IV/OD

6.INJ.ZOFER 4MG/IV/SOS

7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY 

8.SYP.BENADRYL 10 ML/PO/TID

9.T.DOLO 650 MG/PO/TID

10.VITALS MONITORING 


ICU BED 3

Day 1(22/10/22)

S:

Fever spikes +

Cough

O:

Patient is conscious, coherent and co-operative
Temp : 99.5 F
BP : 90/50 mmHg
PR : 102 BPM
RR : 18 CPM
SpO2 : 95%
GRBS : 138 mg/dl


A:
VIRAL PNEUMONIA WITH AKI ON CKD

P:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.IV FLUIDS NS@ UO + 30 ML/HR

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.INJ.PAN 40 MG/IV/OD

6.INJ.ZOFER 4MG/IV/SOS

7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY 

8.SYP.BENADRYL 10 ML/PO/TID

9.T.DOLO 650 MG/PO/TID

10.SYP.CREMAFFIN 10 ML/PO/HS

11.VITALS MONITORING 


AMC BED 6

Day 2(23/10/22)

S:

Fever spikes + (1 spike)

O:

Patient is conscious, coherent and co-operative
Temp : 99 F
BP : 100/60 mmHg
PR : 78 BPM
RR : 24 CPM
GRBS : 113 GM/DL 
RS-BAE+ NVBS
     LT ISA Inspiratory crepts+
P/A- Soft,non tender
CNS-No focal neurological deficits noted


A:
VIRAL PNEUMONIA WITH CKD

P:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.IV FLUIDS NS@ 50 ML/HR

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.SYP.BENADRYL 10 ML/PO/TID

6.SYP.CREMAFFIN 15 ML/PO/SOS

7.TAB.PCM 650 MG PO/BD

8.VITALS MONITORING 


AMC BED 2

Day 3(24/10/22)

S:

Fever spikes + (1 spike)

O:

Patient is conscious, coherent and co-operative
Temp : 100F
BP : 100/60 mmHg
PR : 74 BPM
RR : 24 CPM
GRBS : 89 GM/DL 
RS-BAE+ NVBS
P/A- Soft,non tender
CNS-No focal neurological deficits noted


A:
VIRAL PNEUMONIA WITH CKD

P:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.IV FLUIDS NS@ 50 ML/HR

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.SYP.BENADRYL 10 ML/PO/TID

6.SYP.CREMAFFIN 15 ML/PO/SOS

7.TAB.PCM 650 MG PO/BD

8.SPOROLAC DS

9.VITALS MONITORING 


MEDICAL WARD

Day 4(25/10/22)

S:

Loose stools(1 episode)

Cough

Decreased appetite 

O:

Patient is conscious, coherent and co-operative
Temp : 99 F
BP : 100/70 mmHg
PR : 78 BPM
RR : 22 CPM
GRBS : 136 GM/DL 
RS-BAE+ NVBS
P/A- Soft,non tender
CNS-No focal neurological deficits noted


A:
VIRAL PNEUMONIA WITH CKD

P:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.IV FLUIDS NS@ 50 ML/HR

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.SYP.BENADRYL 10 ML/PO/TID

6.SYP.CREMAFFIN 15 ML/PO/SOS

7.TAB.PCM 650 MG PO/BD

8.TAB.NODOSIS 500MG/PO/OD

9.TAB.SNELLAL 550 MG/PO/OD

10.NEB.DUOLIN BUDECORT

11.VITALS MONITORING 


MEDICAL WARD

Day 5(26/10/22)

Cough

Fever spikes+

O:

Patient is conscious, coherent and co-operative
Temp : 98.4F
BP : 100/70 mmHg
PR : 90 BPM
RR : 22 CPM
GRBS : 149 GM/DL 
RS-BAE+ NVBS
P/A- Soft,non tender
CNS-No focal neurological deficits noted


A:
VIRAL PNEUMONIA WITH CKD WITH POST VIRAL MYALGIA

P:

1.INJ.AUGMENTIN 1.2 GM/IV/BD

2.TAB.ULTRACET PO/BD

3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)

4.T.AZITHROMYCIN 500MG PO/OD

5.SYP.BENADRYL 10 ML/PO/TID

6.SYP.CREMAFFIN 15 ML/PO/SOS

7.TAB.PCM 650 MG PO/BD

8.TAB.NODOSIS 500MG/PO/OD

9.TAB.SNELLAL 550 MG/PO/OD

10.NEB.DUOLIN BUDECORT

11.VITALS MONITORING 


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