PATIENT WITH C/O SOB SINCE 7 DAYS

PATIENT WITH C/O SOB SINCE 7 DAYS

 PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO THEN HE DEVELOPED SOB OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 2 DAYS COUGH + WITH EXPECTORATION,BLOOD TINGED + FEVER + SINCE 7 DAYS ,LOW GRADE NOT WITH CHILLS AND RIGOR,COLDSORE THROAT -, ABDOMINAL PAIN -,VOMITING -,LOOSE STOOLS - N/KC/O CVA,CAD,TB,EPILEPSY K/C/O TB SINCE 7 YEARS AGO USED MEDICATION K/C/O HTN AND DM II SINCE 2 YEARS ON MEDICATION PERSONAL HISTORY APETITE-DECREASED SLEEP-ADEQUATE BOWEL AND BLADDER- REGULAR NO ALLERGIES

 GENERAL EXAMINATION;

PATIENT IS CONSIOUS ,COHERENT,COOPERATIVE 

NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

 VTALS PR-108 BPM BP- 120/60 MMHG RR-22 CPM 

TEMP AFEBRILE SYSTEMIC EXAMINATION : 

CVS : S1 S2 HEARD , NO MURMURS 

RS : BAE +,RHONCI ? 

PER ABDOMEN : SOFT , NON TENDER , NO ORGANOMEGALY 

CNS : HGHER MOTOR FUNCTIONS PRESENT , NO FND 

PULMONOLOGY REFFERAL DONE I/V/O BLOOD TINGED SPUTUM AND PREVIOUS TB ADVISED TRUNAAT,HRCT CHEST 

PULMONOLOGY REVIEW REFERAL WAS TAKEN I/V/O MASS IN RIGHT LUNG ON HRCT CHEST AND WAS ADVICSED FOR BIOPSY


PROVISIONAL Diagnosis 

MASS IN THE RIGHT LUNG WITH DIABETIC KETOSIS WITH ? PNEUMONIA OF RIGHT LUNG WITH K/C/O OLD TB WITH K/C/O HTN AND DM II


RFT 17-10-2023 09:42:PM

 UREA60 mg/dl50-17 mg/dl

CREATININE1.1 mg/dl1.3-0.8 mg/dl

URIC ACID9.9 mg/dl7.2-3.5 mg/dl

CALCIUM10.1 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS4.1 mg/dl4.5-2.5 mg/dl

SODIUM131 mEq/L145-136 mEq/L

POTASSIUM4.2 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

ABG 17-10-2023 09:42:PM 

PH7.41

PCO225.7

PO257.3

HCO316.3

St.HCO319.3

BEB-6.1

BEecf-7.4

TCO231.3

O2 Sat88.4

O2 Count19.2

COMPLETE URINE EXAMINATION (CUE) 17-10-2023 09:42:PM 

COLOURPaleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN+

SUGAR ++++

BILE SALTSNil

BILE PIGMENTSNil

PUS CELLS4-5

EPITHELIAL CELLS3-4

RED BLOOD CELLSNil

CRYSTALSNil

CASTSNil

AMORPHOUS DEPOSITSAbsent

OTHERSNilRFT 18-10-2023 12:12:AM 

UREA86 mg/dl50-17 mg/dl

CREATININE1.2 mg/dl1.3-0.8 mg/dl

URIC ACID10.5 mg/dl7.2- 3.5 mg/dl

CALCIUM9.4 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS5.7 mg/dl4.5-2.5 mg/dl

SODIUM131 mEq/L145-136 mEq/L

POTASSIUM4.6 mEq/L5.1-3.5 mEq/L

CHLORIDE99 mEq/L98-107 mEq/L

ABG 18-10-2023 12:12:AM

 PH7.36

PCO225.9

PO264.8

HCO314.5

St.HCO317.4

BEB-8.8

BEecf9.8

TCO228.4

O2 Sat90.2

O2 Count19.3

LIVER FUNCTION TEST (LFT) 18-10-2023 12:12:AM 

Total Bilurubin4.59 mg/dl1-0 mg/dl

Direct Bilurubin0.37 mg/dl0.2-0.0 mg/dl

SGOT(AST)21 IU/L35-0 IU/L

SGPT(ALT)18 IU/L45-0 IU/L

ALKALINE PHOSPHATE263 IU/L119-56 IU/L

TOTAL PROTEINS6.9 gm/dl8.3-6.4 gm/dl

ALBUMIN2.4 gm/dl4.6-3.2 gm/dlA/G

 RATIO0.53RFT 18-10-2023 04:27:PM 

UREA97 mg/dl50-17 mg/dl

CREATININE1.5 mg/dl1.3-0.8 mg/dl

URIC ACID10.5 mg/dl7.2-3.5 mg/dl

CALCIUM10.0 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS5.8 mg/dl4.5-2.5 mg/d

lSODIUM130 mEq/L145-136 mEq/L

POTASSIUM3.8 mEq/L5.1-3.5 mEq/L

CHLORIDE101 mEq/L98-107 mEq/L

LIVER FUNCTION TEST (LFT) 18-10-2023 04:27:PM

 Total Bilurubin1.94 mg/dl1-0 mg/dl

Direct Bilurubin1.32 mg/dl0.2-0.0 mg/dl

SGOT(AST)51 IU/L35-0 IU/L

SGPT(ALT)20 IU/L45-0 IU/L

ALKALINE PHOSPHATE269 IU/L119-56 IU/L

TOTAL PROTEINS7.4 gm/dl8.3-6.4 gm/dl

ALBUMIN2.1 gm/dl4.6- 3.2 gm/dl

A/G RATIO0.41ABG 18-10-2023 10:55:PM

 PH7.39

PCO228.0

PO278.7

HCO316.9

St.HCO319.2

BEB-6.3BEecf-7.0

TCO234.2O2

 Sat94.7

O2 Count16.2 

USG ABDOMEN AND PELVIS: GRADE II FATTY LIVER RIGHT GRADE I RPD CHANGES LEFT RENAL CORTICAL CYST 

2D ECHO: MILD TR+ TRIVAL TR+ EF 63% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION


HRCT OF CHEST:

 MASS IN RIGHT LUNG PARTIALLY ENCASING THE RIGHT MAIN BRONCHUS AND BRONCHUS TO UPPER LOBE RESULTING IN PARTIAL ATELECTASIS OF RIGHT UPPER LOBE SUGGESTED BRONCHOSCOPIC BIOPSY TO RULE OUT MALIGNANCY SIGNIFICANT MEDIASTINAL LYMPHADENOPATHY RIGHT ADRENAL NODULE -TO RULE OUT METASTASIS MULTIPLE CAVITIES AND SMALL CYSTIC LUECENCIES(?BRONCHIECTATIC) REPLACING TH PARENCHYMA OF THE ENTIRE RIGHT UPPER LOBE AND APICAL SEGMENT OF THE RIGHT LOWER LOBE PULMONARY ARTERT ANEURYSM ARISING FROM THE SEGMENTAL ARTERY TO THE RIGHT UPPER LOBE - RASMUSSENS ANEURYSM



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