A 70 year old male,farmer by occupation, came with chief complaints of
1.cough since 10 days
2.shortness of breath since 10 days
3.decreased urine output since 1 week
4.facial puffiness since 1week
5.b/l pedal edema since 1 week
The patient was apparently assymptomatic 10 years back then he developed chest pain and palpitations for which angiogram was done .2 years back patient developed cough, which was productive ,sputum -whistish in colour, non foul smelling ,not blood tinged, associated with shortness of breath grade 2 acc to NYHA classification ;not associated with orthopnea,PND.
Patient was diagnosed with bronchial asthma 2 years back and was on inhalers since then.
C/o low grade fever (intermittent) since 15 days associated with chills;subsided on medication
K/c/o HTN - since 10 years on tab.Glimi M1
K/C/O DM- since 2 years on tab.amlogen-AT
Personal history
He takes mixed diet ,with normal appetite ,
Bowel and bladder movements are regular.
ADDICTIONS-
Smoking since 50 years (7 packs /day )
now stopped since 2 years
Alcoholic since 40 years ( occasional )
On general physical examination
Patient is c/c/c
Moderately built and well nourished
No pallor , cyanosis, clubbing , lymphadenopathy.
Vitals-
PR- 112 bpm
BP- 140/80 mm hg
Rr- 20 cpm
Spo2 - 98% at ra
Grbs- 112 mg/dl
Provisional diagnosis
Viral pyrexia under evaluation with chronic bronchial asthma with pneumoconiosis (occupational lung disease).
24/10/21
FBS- 1008 mg/dl
Blood urea- 26 mg/dl
Total cholesterol - 160
Hdl- 28mg/dl
Ldl- 47 mg/dl
Vldl- 30.6 mg/dl
Surgery referral I/v/o ? rectal prolapse,? hemorrhoids
Temperature charting
Plan of treatment
1.O2 supplmentation if spo2 <90%
2. Head end elevation upto 30°
3. Neb with duolin -6th hourly , budecort -8th hourly
4. Inj.Pan 40 mg iv OD
5. Inj.hai s/c
6. Tab.montac lc
7. Syrup. Ascoryl po TID
8. Tab.pulmo clear po bd
9. Tab.prednisolone 5 mg po OD
10. Tab.aten am 50/5 mg po OD
Soap notes day 1
S:-no fever spike
O:- Pt c/c/c
Temp- afebrile
BP- 140/90 mm hg
PR- 84bpm
CVS- S1,S2 +
RS- BAE+, b/l Expiratory wheeze pressnt in ISA,IAA
P/A- soft nontender,bowel sounds+
A: viral pyrexia under evaluation
Pneumoconiosis (Occupational lung disease), copd,
Plan of treatment-
1.O2 supplmentation (to maintain spo2>92%)
2. Head end elevation upto 30°
3. Neb with duolin -6th hourly , budecort -8th hourly
4. Inj.Pan 40 mg iv OD
5. Inj.hai s/c tid
6. Tab.montac lc
7. Syrup. Ascoryl po TID
8. Tab.pulmo clear po bd
9. Tab.prednisolone 5 mg po OD
10. Tab.aten am 50/5 mg po OD
11.inj.monocef 1gm iv Bd
12.tab azithro 500mg Po od
13.Tab. amlong 10 mg po od
14.Tab.dolo 65O mg po bd
15.inj.neomol 1 gm sos
16.Strict I/o charting
Soap notes day 2
S:-no fever spike
O:- Pt c/c/c
Temp- afebrile
BP- 120/80 mm hg
PR- 80bpm
Rr- 16 cpm
CVS- S1,S2 +
RS- BAE+, Expiratory wheeze present in rt Infra SA,IMA,interscapular area
Left- SSA, ISA ,INFRA SCAPULAR AREA
P/A- soft nontender,bowel sounds+
A: viral pyrexia under evaluation
Pneumoconiosis (Occupational lung disease), copd,
Plan of treatment-
1.O2 supplmentation (to maintain spo2>92%)
2. Head end elevation upto 30°
3. Neb with duolin -6th hourly , budecort -8th hourly
4. Inj.Pan 40 mg iv OD
5. Inj.hai s/c tid
6. Tab.montac lc
7. Syrup. Ascoryl po TID
8. Tab.pulmo clear po bd
9. Tab.prednisolone 5 mg po OD
10. Tab.aten am 50/5 mg po OD
11.inj.monocef 1gm iv Bd
12.tab azithro 500mg Po od
13.Tab. amlong 10 mg po od
14.Tab.dolo 65O mg po bd
15.inj.neomol 1 gm sos
16.Strict I/o charting
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