A 61 year old patient with complaints of fever,SOB and cough since 5 days

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Here is a case i have seen:

 61 year old male farmer by occupation and a resident of nakrekal got married 40years ago.His wife is a home maker.He has three children,two daughters who got married and a younger son got married and working as a farmer.Patient used to do his daily activities and farming since diwali 2019.Post diwali patient was complaining of generalised weakness,SOB and palpitations while doing his manual labour work.patient had been home since then.

H/O deviation of mouth to right side was present since ?10years and left side ptosis present and loss of wrinkling on left side(?Left side Bell’s palsy)Patient and his attenders did not give much attention to it since there was no limb weakness,difficulty in speech or swallowing.No other complaints 

Post diwali in 2019 patient was complaining of generalised weakness,SOB and palpitations while doing his manyal labour work.patient had been home since then.

Patient was apparently asymptomatic 3 months back,then he developed fever for which he was taken to a hospital and was diagnosed with typhoid and treated in hospital,during routine investigations patient attenders were informed that the patient had kidney problem and need further evaluation.patient was on irregular medications. Later patient had  fever on/off and decreased urine output,generalised weakness, was taken to a local hospital and referred here in view of raised creatinine.

Patient presented with complaints of SOB since 5 days, fever since 5 days and cough since 5 days.

 Fever - lowgrade,intermittent,reduced on medication

H/0 SOB since 5 days (grade 3)

Cough with sputum since 5 days sparse in quantity,non blood stained

K/C/O CKD since 3months and on conservative management

Not a K/C/O DM,HTN ,TB ,Epilepsy,CAD,

H/o alcohol consumption for 25 years,stopped 1 year back,consumed toddy and 180ml of whisky

H/O smoking-(chutta) for 15years, stopped 10years back

O/E: pt is conscious,coherent and cooperative

BP- 130/80mm Hg

PR- 98 bpm

RR- 28cpm 

Cvs -S1S2 present. 

RS- 

Inspection - Shape of chest elliptical and bilaterally symmetrical .

No dropping of shoulder

No visible apex beat .

No shifting of trachea .

No scars ,sinuses ,no kypho scoliosis.

Palpation - 

Trachea is in midline .

Apical impulse felt in left 5th intercostal space in mid clavicular line .

Decreased  chest expansion on left side .(Anterior ,posterior and upper thoracic movements.) 

Decreased vocal fremitus on left MA ,SCA ,ICA,ISA,inter scapular areas. IAA ,SSA .

 

 PERCUSSION:

Stony  dullness present on left side - MA,AA,IAA ,SSA,ISA.

AUSCULTATION:

— Decreased breath sounds on left Inter SA,Infra SA,AA,IAA,MA

—crepts heard in right InfraSA,AA,IAA

P/A- soft,non tender

CNS- 

Loss of forehead wirnkles on left side 

Difficutly to close his left eye

Deviation of mouth to right side.

No other focal neurological deficits .

INVESTIGATIONS:

ECG

Sputum ZNstaining showing scanty staining

USG-

CHEST X-RAY

Massive pleural effusion shitfing lower and middle mediastinum to right

Pleural fluid tapping was done on 9-1-21 and 1lit of fluid was removed and sent for analysis

Pleural fluid protein- 3.5

 Sugar-67

LDH-201

According to light’s criteria 

Pleural protein/Serum protein= 1.25(>0.5)

Pleural LDH/Serum LDH=0.7(>0.6)

Inference:- Exudative pleural effusion

Pleural fluid cellcount-

Dc- 95% lymphocyes 

05% neutrophils

Tc - 125 cells

Pleural fluid cytology showed negative for malignancy

Xray(14-1-21)

PATIENT WAS TAKEN FOR DIALYSIS AT 4:00pm on 8-1-21 ; UF WAS 1lit; SOB DECREASED 

UREA DECREASED FROM 223 to 138

Dialysis done on 11-1-21 and ultrafiltrate was 1lit

Dialysis done on 14-1-21 and UF was 1lit

Dialysis done on 17-1-21 and UF was 500ml

TREATMENT:

1-SALT AND FLUID RESTRICTION

2-TAB.LASIX 40mg PO/BD

3-T.NODOSIS 500mg PO/TID

4-T.SHELCAL CT PO/BD

5-T.OROFER XT PO/OD

6-INJ PIPTAZ 2.25gm IV TID

7- BP/PR/TEMP/SPO2 MONITORING

18-1-2021

Pt was started on ATT

pt was c/o SOB and excessive sweating

Having sudden hypotension(bp 80/60) and sudden fall of saturation to 70% -connected to BIPAP.Abg showed Ph 7.3.pco2. 15.8 Hco3  8.(severe metabolic acidosis)

100ml NS bolus was given.Bp was 70/60 .Pt was started on nor ad infusion and grbs was 57mg/dl.25D was given after which grbs was 144mg/dl.on intermittent BiPAP sats were maintained at 95% for some time .

Again there was sudden fall of saturation and sudden cardiac arrest.Patient was intubated and immediate CPR was initiated.Even after 8cycles of CPR pt could not be revived and ecg showed flat line and declared dead on 18/1/2021