50 year old make with c/o giddiness

 CBBLE UDHC SIMILAR CASES

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

50 year old male  who is a  labourer by occupation came to the casuality with complaints of giddiness since 2 hours

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 2 hours back & then  c/o giddiness , non postural , not associated with vertigo / tinitus 

C/O fever , insidious in onset , gradually progressive in nature , relieved on taking medication 

No c/o shortness of breadth, palpitations , orthopnea/ pnd

PAST HISTORY : 

20 years back while he was working with his co workers he had episodes of sob when he was to hospital and diagnosed with pneumonia

30 days back he had c/o fever and vomitings  and taken to a hospital where he was diagnosed with typhoid and jaundice and he was given medication as fever and cough did not subside Sputum for afb was done which is negative but the patient was given medication isoniazid and ethambutol which he used for 20 days and then patient became weak , appetite reduced , and unable to go to his work 

Alcoholic since 20 years 

Smoker since 20 years 

not a known case of DM, HTN , bronchial asthma , epilepsy 

SURGICAL HISTORY:no significant surgical history 

PERSONAL HISTORY:

Married 

Labourer  by occupation 

Appetite:decreased since 10 days

Bowel bladder movements: regular 

Addictions: alcohol consumption since 20years ( 90 ml whiskey  everyday)

Smoker since 20 years

O/E :  

Patient is consious , coherent and cooperative ,well oriented to time,place,person

Pallor + 

No signs of icterus,clubbing,cyanosis,lymphadenopathy,pedal edema

Bp:100/80 mm hg 

PR : 91bpm

RR: 17 cpm

GRBS: 95 mg/dl 

SYSTEMIC EXAMINATION:

Cvs : s1 s2 +

Rs : BAE +

P/A: soft , non tender 

INVESTIGATIONS:

ECG:

2D echo: 

EF-55%

Trivial Tr+/no Mr , trivial Ar+

Good LV systolic function +

Diastolic dysfunction + 

X ray :

Sputum for afb:

ZN stain - acid fast bacilli seen 

                Grade - scanty

 

Usg abdomen : 

Findings: 1)E/O  air bronchogarm in right lung 

2)E/O 5 mm hyperechoic focus noted adherent to Gb wall 

Imp: 

1) Gall bladder wall edema 

2) right lung consolidation 

3)gall bladder wall polyp 

PROVISIONAL DIAGNOSIS: 

hypokalemic periodic paralysis secondary to ? Acute ge ? Alcohol with left lower lobe pneumonia with  Diselctrolytemia with alcoholic hepatitis with SIADH secondary to ? bronchogenic carcinoma 

Plan: 

1) Ivf ns/ rl @ 100 ml/hr 

2)Inj pantop 40 mg IV/od 

3)Inj zoefer 4 mg IV/sos 

4)tab udilin 500mg po/BD 

5) inj thiamine 1 amp in 100 ml ns iv/ TID 

6)syp potlhlor 10 ml po/tid in glass of water

Soap notes:

Amc 

Day 2 

Bed 3

S : 

Fever spike +

O -  Patient is conscious,coherent,cooperative

vitals :

Temp   -  100.1F

BP        - 100/60 mm hg 

PR       -  84 bpm. 

RR       - 18 cpm 

spo2    - 100 @RA 

GRBS   - 111 mg/dl @  8 am

CVS     - S1, S2 heard , no murmurs

RS       - Nvbs+, no crepts , reduced breath sounds in left IPA, IAA 

P/A     -  Soft , Non tender

bowel Sounds - Present

A -  hypokalemic periodic paralysis secondary to ? Acute ge ? Alcohol with left lower lobe pneumonia with  Diselctrolytemia with alcoholic hepatitis with SIADH secondary to ? bronchogenic carcinoma 

P -

1) Ivf ns/ rl @ 100 ml/hr 

2)Inj pantop 40 mg IV/od 

3)Inj zoefer 4 mg IV/sos 

4)tab udilin 500mg po/BD 

5)syp potlhlor 10 ml po/tid in glass of water

6)INJ monocef 1gm/IV/BD (day1)

7)2 scoop of protein powder in 100 ml milk/ water po/TID 

8)Ascoryl syrup po/TID 

9)monitor vitals  hourly 

Plan for HRCT and Usg abdomen