A 75 YEAR OLD MALE WITH PYREXIA UNDER EVALUATION, ? CHRONIC BRONCHITIS ( PAST HISTORY OF TB)

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A 75 year old came to the casualty with c/o 
fever, cold, cough since 4 days.

patient was apparently asymptomatic till 2003 , then patient had B/L knee pain which gradually aggravated, then patient was started on NSAID'S daily for 3 years.

Then in 2006- one day pt had continuous episodes of loose stools, 12-14 episodes per day with ? Anuria. 
In view of anuria he went to nephrologist > ? AKI > Advised dialysis > patient underwent 1 session of hemodialysis.

2 YEARS BACK : pt experienced Polyuria , polydypsia for 2 days for which he visited nearby RMP and was diagnosed as DIABETIC and started on OHA.

At present since 10 DAYS , patient had decrease of appetite, generalised weakness> took OHA and didn't take any food. Then Patient experienced 1 episode of hypoglycemia GRBS: 18 mg/dl ( frothing and uprolling of eyes). Then his attender gave him sugar water and 25 D Infusion in ambulance- Recovered.
Had similar episode 2 days back.
decrease in Appetite since 10 days.

k/c/o Diabetes since 10 years

Addictions: Chronic smoker ( chutta) 5-6/day for 30 years




O/E
Temp: 96.9 F
PR: 68 bpm.
BP: 120/90 mm hg.
Spo2 : 98% @ RA.
CVS: S1 S 2 heard
RS: wheeze+ fine crepts+ bilaterally.
P/A : soft, non tender.
CNS: NAD.

PROVISIONAL DIAGNOSIS: Pyrexia under Evaluation with DM type 2. ? Chronic bronchitis.

TREATMENT given:
- IVF NS @ 20 ml/kg/hr IV stat.
Ns @ 10ml/kg/hr continuous.
-Inj. PANT OP 40MG IV/OD.
-INJ.ZOFER 4 mg IV/SOS
- INJ.NEOMOL 1gm IV/SOS ( temp > 101 F)
- Inj. HAI S/C according to sliding scale.
- Nebulisation with BUDECORT 12th hrly.
- Grbs 6 th hrly.
- vitals monitoring 4 th hrly.

Investigations
Hemogram on 24/9/21






Nephro referral





CLINICAL IMAGES

 SOAP NOTES
A 75 yr old male with Pyrexia under evaluation.

Subjective- 2 episodes of loose stools, fever with chills.

Objective
Temp: 99.1 F
BP: 110/50 mmhg
PR: 90 bpm
Cvs: S1 S 2 +
Rs: B/L fine Crepts in SA,SSA,ISA. Wheeze +
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
? CHRONIC bronchitis
Analgesic Nephropathy.
Past history of TB

Treatment
IVF NS RL@ 150 ml/hr.
Inj. Pant op 40 mg IV/ OD.
Inj.Zofer 4mg IV/ SOS.
Inj. Neomol 1g IV/ SOS.
Inj.HAI s/c according to sliding scale.
Inj.DERIPHYLLIN 2 cc IV/ BD.
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly.
T.PREGABALIN 75 mg OD(9pm).
T.Azitromycin 500 mg PO/ OD(D2)
Grbs 6th hrly.
Vitals monitoring 4 th hrly.


Soap notes
A 75 yr old male with Pyrexia under evaluation.
 
Subjective-1 episode of fever (101F)

O
Temp: 100 F
BP: 100/60 
PR: 84 bpm
Cvs: S1 S 2 +
Rs: B/L Crepts in SA,SSA,ISA. Wheeze +
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
? CHRONIC bronchitis
Past history of TB

Treatment
IVF NS RL@ 150 ml/hr
Inj.Augmentin 1.3 gm IV/BD(D1)
Inj. Pant op 40 mg IV/ OD
Inj.Zofer 4mg IV/ SOS
Inj. Neomol 1g IV/ SOS
Inj.HAI s/c according to sliding scale
Inj.DERIPHYLLIN 2 cc IV/ BD
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly.
T.PREGABALIN 75 mg OD(9pm)
T.Azitromycin 500 mg PO/ OD(D3)
Grbs 6th hrly
Vitals monitoring 4 th hrly

Soap notes
A 75 yr old male with Pyrexia under evaluation.
 
Subjective- fever (101F)

O
Temp: 100.9 F
BP: 110/60 
PR: 74 bpm
Cvs: S1 S 2 +
Rs: B/L  Crepts in SA,SSA,ISA. Wheeze +
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
? CHRONIC bronchitis,Analgesic nephropathy
Past history of TB,Aki on CKD.

Treatment
Inj.Tazar 2.25 mg IV/TID.
Tab Pant op 40 mg po/ OD
Inj.Zofer 4mg IV/ SOS
Inj. Neomol 1g IV/ SOS
Inj.HAI s/c according to sliding scale
Inj.DERIPHYLLINE 2 cc IV/ BD
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly.
T.PREGABALIN 75 mg OD(9pm)
T.Azitromycin 500 mg PO/ OD(D3)
Grbs 6th hrly
Vitals monitoring 4 th hrly


A 75 yr old male with Pyrexia under evaluation.
 
Subjective- no fresh complaints.

O
Temp: 99 F
BP: 102/64 mm hg
PR: 91 bpm
Cvs: S1 S 2 +
Rs: B/L  Crepts in SA,SSA,ISA.
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
? CHRONIC bronchitis,Analgesic nephropathy
Past history of TB,Aki on CKD.

Treatment
Oral intake of fluids.
Inj.Tazar 2.25 mg IV/TID.(D2)
Tab Pant op 40 mg po/ OD
Inj.Zofer 4mg IV/ SOS
Inj. Neomol 1g IV/ SOS
Inj.HAI s/c according to sliding scale
Inj.DERIPHYLLINE 2 cc IV/ BD
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly, mucomist-12 th hrly
T.PREGABALIN 75 mg OD(9pm)
T.Azitromycin 500 mg PO/ OD(D6)
Syp.Ascoril 10ml po/BD 
Grbs 6th hrly
Vitals monitoring 4 th hrly

Soap notes
A 75 yr old male with Pyrexia under evaluation.
 
Subjective- no fresh complaints.

O
Temp: 98.6 F
BP: 100/60mm hg
PR: 94 bpm
Cvs: S1 S 2 +
Rs:  Crepts +
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
? CHRONIC bronchitis,Analgesic nephropathy
Past history of TB,Aki on CKD.

Treatment
Oral intake of fluids.
Inj.Tazar 2.25 mg IV/TID.(D3)
Tab Pant op 40 mg po/ OD
Inj.Zofer 4mg IV/ SOS
Inj. Neomol 1g IV/ SOS
Inj.HAI s/c according to sliding scale
Inj.DERIPHYLLINE 2 cc IV/ BD
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly, mucomist-12 th hrly
T.PREGABALIN 75 mg OD(9pm)
T.Azitromycin 500 mg PO/ OD(D7)
Syp.Grilnicterus po/BD 
Grbs 6th hrly
Vitals monitoring 4 th hrly.

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