GENERAL MEDICINE CASE DISCUSSION.

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A 65 year old patient came to the casualty with the chief complaints of :

1. Fever 1 month back

2. Cough since 20 days

3. Shortness of breath since 20 days (class II - class III) according to NYHA classification, not associated with orthopnea/PND.

4. Fever since 20 days , not associated with chills and rigor.

Patient was apparently asymptomatic 20 days back, then he developed fever which was insidious in onset, gradually progressive and subsided on taking medication.

Complain of cough , associated with sputum , yellowish in colour, non blood tinged, non foul smelling.

Not a k/c/o DM, HTN,  asthma, TB.

Patient is on Tab OLANZEPINE 5mg, Tab ESCITALOPRAM -10mg since 2 years due to personality disorder.

Vitals on admission :

Temperature - 97 F

Pulse rate - 83 BPM

Respiratory rate -16 cpm

Blood pressure - 140/90 mm Hg

SpO2 - 99% at room air.

On examination :

Patient is irritable i

CVS - S1 S2 heard, no murmurs

RS - NVBS present

CNS - NAD

P/A - soft, non tender

INVESTIGATIONS :

Serology was found to be negative.

USG Abdomen- 

1. Right grade II RPD

2. Left grade I RPD

3. Mild Splenomegaly

Provisional diagnosis : COMMUNITY ACQUIRED PNEUMONIA OF RIGHT LOWER LOBE WITH PANYTOPENIA.

? AKI ON CKD.

Treatment :

1. O2 supplementation if SpO2<90%

2. Inj NEOMOL 100ml / IV/ if temperature> 101.1 F

3. Tab DOLO 650mg /PO/BD

4. Syp ASCORYL 10ml/PO/BD

5. Nebulization with IPRAVENT and BUDECORT - 6th hourly

6. Inj PAN 40mg /IV /OD.

On 24/11/2021,

S-cough with expectoration+,pt is standing up and micturating on the floor, sleep:pt woke up every hour and randomnly stood beside the bed .

no fever spike

O- conscious, intermittent coherent.

orientated only to person.

speech-slurred

memory -couldnt be elicited.

afebrile-

PR-121/min

BP-130/80mmhg

cvs:s1,s2+

r.s: bae+coarse crepts end insp,b/l ll, rt>lt

intermittent end exp wheeze +

spo2 on room air:94%

p/a:soft nt

BUN/creat:36.6(pre renal)

output: 1200ml till last night,not measured after that

usg-mild spleenomegaly.

A- B/L lowerlobe consolidation secondary to ? community acquired pneumonia

pancytopenia secondary to ?infection ? spleenomegaly.

AKI (pre-renal ) on ckd

h/o using antipsychotics since 2.5 years

P-inj ceftriaxone 1g/iv/bd

ivf -ns,rl@100ml/hr

neb with ipravent, budecort

syp ascoryl 10ml/po/tid

tab dolo 650mg/po/bd

with holding antipsychotics as per psychiatry consultation orders.

On 25/11/2021,

S - Patient is irritable

Fever spikes present

O - Patient is irritable, oriented only to person

Speed - slurred

Temperature - 99 F

PR - 83bpm

BP - 120/70mm Hg

RR - 22/min

CVS - S1 S2 +, no murmurs

RS - NVBS heard, crepts present in right IAA, ISA

SpO2 - 98% at room air

GRBS - 105 gm/dl

I/O - 700/950 ml

A : Community Acquired Pneumonia in right lower lobe with pancytopenia with AKI on CKD

P :

1. O2 supplementation if SpO2 < 90%

2. Tab AZITHROMYCIN 500mg PO/OD

3. Tab PAN 40mg PO /OD

4. Tab DOLO 500 mg PO / TID

5. Nebulization with IPRAVENT and BUDECORT every 6th hourly

6. Syp ASCORYL 10ml PO/ TID

7. Tab OLZIC 5mg / PO H/S

8. Vitals monitoring

On 26/11/2021 :

S - Patient is irritable

Fever spikes present

Thrombophlebitis present

O - Patient is irritable, oriented only to person

Speed - slurred

Temperature - 99.5 F (febrile)

PR - 98bpm

BP - 120/70mm Hg

RR - 22/min

CVS - S1 S2 +, no murmurs

RS - NVBS heard, bilateral crepts present in right IAA, ISA

SpO2 - 98% at room air

GRBS - 119 gm/dl

I/O - 700/950 ml

A : Community Acquired Pneumonia in right lower lobe with pancytopenia (resolving) with fever under evaluation with AKI on CKD

P :

1. O2 supplementation if SpO2 < 90%

2. Tab AZITHROMYCIN 500mg PO/OD

3. Tab PAN 40mg PO /OD

4. Tab DOLO 500 mg PO / TID

5. Nebulization with IPRAVENT and BUDECORT every 6th hourly

6. Syp ASCORYL 10ml PO/ TID

7. Tab OLZIC 5mg / PO H/S

8. Vitals monitoring

9. Fever Charting 4th hourly.

27/11/2021 :

Unit 1 

S - Patient is irritable

Fever spikes present

Passed stools

O - Patient is irritable, oriented only to person

Speed - slurred

Temperature - 99.5 F (febrile)

PR - 89bpm

BP - 120/70mm Hg

RR - 22/min

CVS - S1 S2 +, no murmurs

RS - NVBS heard, bilateral crepts present in right IAA, ISA

SpO2 - 98% at room air

GRBS - 119 gm/dl

I/O - 700/950 ml

A : Community Acquired Pneumonia in right lower lobe with pancytopenia (resolving) with fever under evaluation with AKI on CKD

P :

1. Inj AUGMENTIN 1.2gm /IV /BD 

2. Tab AZITHROMYCIN 500mg PO/OD

3. Tab PAN 40mg PO /OD

4. Tab DOLO 500 mg PO / TID

5. Nebulization with IPRAVENT and BUDECORT every 6th hourly

6. Syp ASCORYL 10ml PO/ TID

7. Tab OLZIC 5mg / PO H/S

8. Tab PREGARALIN 75mg /PO / SOS

9. Vitals monitoring

10. Fever Charting 4th hourly.