45 years Male old patient with Shortness of Breath and Abdominal pain
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A 48 year old Male patient came to the hospital with the chief complaints of
* Cough since 1 month
* Shortness of Breath since 1 month
* Abdominal pain since 5 days
History of present illness :
* Patient was apparently asymptomatic 1 month back and then he developed
* Cough since 1 month which is
▪️ Insidious in onset
▪️ Associated with sputum
* Shortness of Breath which is :
▪️ Insidious in Onset.
▪️ Aggravated on Exertion and walking.
▪️ Not associated with Wheezing, Sweating and palpitations
* Abdominal pain since 5 days
▪️Located at Right hypochondrial, Epigastric and Umbilical region
▪️ Diffuse in nature
* Not associated with Chest tightness, fever, Vomiting.
History of Past illness :
* No History of Similar Complaints in the Past.
* He is a Case of De novo diabetes mellitus.
* Not a Known Case of Hypertension, Asthma, Epilepsy, Coronary Artery Disease.
Personal History :
Diet - Mixed
Appetite - Normal
Sleep - Inadequate
Bowel and Bladder Movements - Regular
Addictions -
▪️ Alcohol consumption since 30 years 750 ml per day.
▪️Smoking since 35 years amd stopped 20 years back.
Family History :
Not significant
Physical Examination :
A. General Examination
* Patient is conscious, coherent and co-operative and lying on the bed.
* He is well oriented to time, place and person.
* He is mildly nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
Vitals:
Temperature - Afebrile
Pulse Rate - 44 BPM
Blood Pressure - 120/80 mm Hg
Respiratory Rate - 22 CPM
SPO2 - 97% at Room Air
Random Blood Sugar - 301 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, Left ICD insitu
PER ABDOMEN - Distended, Guarding and Rigidity present.
CENTRAL NERVOUS SYSTEM - E4V5M6, Moving all the four limbs against gravity,
11/08/2022
12/08/2022
13/08/2022
14/08/2022
45 year old Male Patient was referred from Pulmonology department to General medicine department with the Sputum positive Pulmonary Koch's with Left sided moderate pleural Effusion with De novo Diabetes mellitus and ICD in situ referred in view of CT scan showing Bilateral bulky adrenal glands. Patient is on Anti Tubercular Therapy since 1 month.
* Chief complaints - Pain Abdomen in Right Hypochondrial, Epigastric and Umbilical region.
* On Examination, Patient is Drowsy but Arousable.
* Vitals -
▪️ Temperature - 99.3 F
▪️ Pulse Rate - 128 BPM
▪️ Blood pressure - 80/50 mmHg
▪️ Respiratory rate - 54 cpm
▪️ SPO2 - 97% on RA
* No passage of Stools
* No urine output since yesterday
* Per Abdomen - Diffuse Tenderness and Sluggish bowel sounds
* Central Nervous system - E4V5M6, Slurring of Speech, Moving all the four limbs against gravity and Bilateral pupil reactive.
* CECT - Bilateral Adrenal gland Bulky ? Infective Pathology.
* USG Abdomen - Cholilithiasis with size of 2.5 cmand sluggish Peristalsis.
* ABG -
▪️ PH - 7.25
▪️ PCO2 - 16.1
▪️ PO2 - 77
▪️ HCO3 - 11.7
▪️SPO2 - 91%
* 2D Echo -
▪️ IVC - Normal
▪️ LVEF - 58 %
▪️ No RWMA
* Provisional Diagnosis - Bilateral Adrenalitis secondary to Adrenal Tubercular with ? Adrenal Insufficiency.
15/08/2022
Diagnosis -
? Primary Adrenal Insufficiency secondary to ? Adrenal Tuberculosis ( Bilateral Adrenalitis ) with Acute Kidney Injury with active Pulmonary Koch's with Left sided ICD insitu for Moderate pleural Effusion
Treatment -
* IV FLUIDS 0.9%NS and 5% DEXTROSE @150 ml/hr
* INJ PAN 40mg IV/BD
* INJ NEOMOL 1gm IV/TID
* INJ TRAMADOL 1amp in 100 ml NS /IV/SOS
* INJ HYDROCORTISONE 200 mg in 500 ml NS @ 2.5 ml/hr
* INJ MEROPENEM 500 mg IV/OD
* TAB NODOSIS 500 mg PO/TID
* Continue ATT
* Hourly monitoring of Blood pressure, Respiratory rate, Pulse rate, Temperature and SPO2.
* GRBS monitoring 4th hourly.
* INJ 25 % DEXTROSE IV/SOS/only if GRBS<70mg/dl
SOAP NOTES : 17/08/2022
C/C - Pain abdomen
Burning Micturition
Objective - Edema present
Decreased breath sounds
PR - 96 bpm
BP - 90/60 mmHg
RR - 26 cpm
Spo2 - 98 % on RA
Assessment -
SOAP Notes 19/08/2022 :
S: decreased pain Abdomen
O:
Patient is conscious,coherent and cooperative
BP-130/70 mm Hg
PR- 84 bpm
RR- 26 cpm
Temp- Afebrile
Spo2 - 96% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender,no organomegaly
CNS-NAD
A : ?? Primary adrenal Insufficiency secondary to Adrenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. INJ. HYDROCORT 100 MG IV/OD
2. TAB.PLM 650 MG PO/SOS
3. TAB. PAN 40 MG PO/OD
4. CONTINUE ATT (RENAL DOSE)
5. BP/PR/RR/SPO2 MONITORING 4TH HOURLY
6. TAB. NODOSIS 500 MG PO/BD
7. INJ. MEROPENEM 500 MG IV/ OD
9. INJ. 8AM. 2PM. 8PM
NPA. 4 units. 4units
HAI. 4 units. 4 units. 2 units
SOAP Notes 20/08/2022 -
Subjective -
S: decreased pain Abdomen
Pedal edema present
O:
Patient is conscious,coherent and cooperative
BP-120/80 mm Hg
PR-72 bpm
RR-24cpm
Temp- Afebrile
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender,no organomegaly
CNS-NAD
A : ?? Primary adrenal Insufficiency secondary to Adrenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. INJ. HYDROCORT 100 MG IV/OD
2. TAB.PLM 650 MG PO/SOS
3. TAB. PAN 40 MG PO/OD
4. CONTINUE ATT (RENAL DOSE)
5. BP/PR/RR/SPO2 MONITORING 4TH HOURLY
6. TAB. NODOSIS 500 MG PO/BD
7. INJ. MEROPENEM 500 MG IV/ OD
8. TAB. LASIX 20 MG PO/OD
9. INJ. 8AM. 2PM. 8PM
NPH. 4 units. 4units
HAI. 4 units. 4 units. 2 units
10. TAB. LASIX 80 MG PO/OD if sbp > 120 mmHg
RICU
45 YEAR OLD MALE
ADMITTED ON 14/08/2022
21/08/2022 :
S: decreased pain Abdomen
Pedal edema present
O:
Patient is conscious,coherent and cooperative
BP-130/90 mm Hg
PR-80 bpm
RR-26 cpm
Temp- Afebrile
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender,no organomegaly
CNS-NAD
A : ?? Primary adrenal Insufficiency secondary to A
drenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. INJ. HYDROCORT 100 MG IV/OD
2. TAB.PLM 650 MG PO/SOS
3. TAB. PAN 40 MG PO/OD
4. CONTINUE ATT (RENAL DOSE)
5. BP/PR/RR/SPO2 MONITORING 4TH HOURLY
6. INJ. MEROPENEM 500 MG IV/ OD
7. TAB. LASIX 20 MG PO/OD
8. INJ. 8AM. 2PM. 8PM
NPH. 4 units. 4 units
HAI. 4 units. 4 units. 2 units
9. 2 egg whites daily
RICU
45 YEAR OLD MALE
ADMITTED ON 14/08/2022
22/08/2022
S: decreased pain Abdomen
O:
Patient is conscious,coherent and cooperative
BP-140/90 mm Hg
PR-84 bpm
RR-24 cpm
Temp- Afebrile
spo2 - 97 % on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender,no organomegaly
CNS-NAD
A : ?? Primary adrenal Insufficiency secondary to Adrenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. INJ. HYDROCORT 100 MG IV/OD
2. TAB.PLM 650 MG PO/SOS
3. TAB. PAN 40 MG PO/OD
4. CONTINUE ATT (RENAL DOSE)
5. SYP. POTKLOR 15 ml PO /BD in1 glass of water
6. BP/PR/RR/SPO2 MONITORING 4TH HOURLY
7. TAB. LASIX 20 MG PO/OD
RICU
45 YEAR OLD MALE
ADMITTED ON 14/08/2022
23/08/2022
S: decreased pain Abdomen
O:
Patient is conscious,coherent and cooperative
BP - 130/80 mm Hg
PR - 90 bpm
RRv- 24 cpm
Temp- 100.7 F
spo2 - 97 % on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender
CNS - NAD
A : ?? Primary adrenal Insufficiency with septic shock secondary to vancomycin resistant enterococcus with Adrenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. INJ. HYDROCORT 100 MG IV/OD
2. TAB.PLM 650 MG PO/SOS
3. TAB. PAN 40 MG PO/OD
4. CONTINUE ATT (RENAL DOSE)
5. SYP. POTKLOR 15 ml PO /BD in1 glass of water
6. BP/PR/RR/SPO2 MONITORING 4TH HOURLY
7. OINT THROMBOPHOB for L/A / BD
8. INJ. 8AM. 2PM. 8PM
NPH. 4 units. 4 units
HAI. 4 units. 4 units. 2 units
RICU
45 YEAR OLD MALE
ADMITTED ON 14/08/2022
24/08/2022
S: decreased pain Abdomen
O:
Patient is conscious,coherent and cooperative
BP - 120/70 mm Hg
PR - 110 bpm
RR- 24 cpm
Temp- 98.3 F
spo2 - 98% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft ,non tender,no organomegaly
CNS-NAD
A : ?? Primary adrenal Insufficiency with septic shock secondary to vancomycin resistant enterococcus with Adrenal TB (bilateral Adrenalitis) with AKI with acute Pulmonary Koch's
P:
1. IV FLUIDS RL @ 50 ml/hr
NS @ 50 ml/hr
2. INJ. LINEZOLID 600 mg/IV/BD
3. INJ. NEOMOL 1gm/IV/SOS
4. TAB. PAN 40 mg/PO/OD
5. TAB. DOLO 650 mg /PO/TID
6. CONTINUE ATT (RENAL DOSE)
7. TAB. LASIX 20 mg /PO/BD
8. OINT. THROMBOPHOB FOR L/A
9. BP/PR/GRBS MONITORING 4TH HOURLY
