70year old male with Acute excebaration copd? With cor pulmonale, with type one renal failure with grade 2 prostatomegaly
Pt came with c/o of fever since 5 days and
Sob since 1 day, decreased urine output since 5 days
Patient was apparently asymptomatic and then developed fever which is intermittent, increased during night not associated with chills and rigor and relivied on medication
And sob grade 2 mmrc since one day now progressed to grade 3, no relieving factors, not associated with wheeze, no h/o chest pain chest tightness, hemoptysis, orthopnea, pnd
Past history:
10 years back he had episodes of cough with sputum episodes of cough lasting for 5 to 10 minutes and used inhaler for it on and off for one year
2 years back he was admitted in the hospital for abdominal tightness and decreased urine output and got admitted in the hospital and treated( bph?)
H/o of loss of consciousness 1 year back and then got admitted at nalgonda private hospital and got treatment
No past h/o tb ,loose of weight,
N/k/c/o DM , HTN, , epilepsy, bronchial asthama,
Known smoker from 50 years, one pack per day( beedi)
K/c/o CAD, BPH. And on medication ecosprin 75 mg , dytor 10, urilosin n
General examination:
Pt is c/c/c moderately nourished and built
Bp : 90/60mmhg
Pr: 82bpm
Rr: 17
Grbs : 118mg/ dl
Cvs : s1 s2 heard
Rs : crepts heard at left infraaxillary area
Cns : no fnd
P/ a : soft non tender
Personal history:
Diet: mixed diet
Appetite: normal
B/b : regular
Sleep : adequate
Daily routine:
He is a farmer wakes up early in the morning at 7 am and has breakfast goes to paddy feilds and works in the feilds and goes back to home and has his lunch, and goes back to work and completes his work by 4 30 , has his tea and freshens up and watches tv and has dinner at 8.30 pm and sleeps by 9.30 pm
But from past 2 years his routine gas been changed due to sob and he is staying at home dependent on his son financially, he has breakfast at 9am, lunch at 1pm and takes nap, does cycling, talks to neighbours , watches tv, and has dinner 8pm , sleeps at 9pm
Provisional diagnosis: Acute excebaration copd? With cor pulmonale with type one renal failure with grade 2 prostatomegaly
Investigations
On 17/8/23
On 16/8/23
Rft
Hemogram
15/8/23
Treatment
Inj.norad in 46 ml ms 1 ml /hr to maintain MAP. More than or equal to 65 mg
Inj. Ceftriaxone 1gm iv bd
T.nitrofurantoin 100 po bd
T.pcm 650 mg po sos
T.tamsulosin po hs
T.ecosprin av 75/10 po hs
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