83 yr old male Cap?

 NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

This is case of 83yr old male came with complaints of cough with sputum since 4 days,breathlessness since 4 days.

Patient was apparently asymptomatic 4days back then he developed  cough which was insidious in onset, gradually progessive associated with sputum which was white in colour ,copious  amount.

Fever since 4 days,high grade, associated with chills and rigors

Breathlessness since 4 days which was insidious in onset , gradually progressive from grade 2 to grade 4

No h/o chest pain, orthopnea,pnd, palpitations,pnd

PAST HISTORY:

Patient is not a known case of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders

PERSONAL HISTORY:

Diet - Mixed

Appetite - decreased

Sleep - Adequate

Bowel and Bladder movements- Regular

Addiction - consumption of alcohol occassionally,h/o smoking since 30 yrs (1pack per day)

GENERAL EXAMINATION 

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

He is moderately built

There is presence of pallor ,pedal edema up to the knee

No cyanosis, clubbing, lymphadenopathy

Vitals on admission - 

Temp - 

BP - 90/60 mm hg 

PR - 98bpm 

RR- 26cpm 

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard , no murmurs 

CNS: NAD 

RS:dysnea is present,B/L air entry + , trachea central , b/l crepitations,bronchial breath sounds

P/A : scaphoid, soft, non tender, bowel sounds are heard 

Dvl referral was done I/v/o lesions in mouth 

Which was diagnosed as oral candidasis

Advised -candid mouth plant l/A bd -2 weeks

Betadine gargle-3 times in a day

Bronchoscopy was done-white plague visualised near vocal cords and left pyriform fossa

Provisional diagnosis: community acquired pneumonia.

Treatment given: DNS,RL @75ml /hr

Inj.piptaz 4.5g iv 8 hrly

Tab.levofloxacin 750 mg po/od

Tab.bactrim-ds 800/160 po/bd

Cap.flucanazole 200mg po/od

Cap.doxycycline 100 mg po/bd

Inj pan 40 mg iv/od

Inj.neurobion 1 amp in 1000 ml ns

Syp.grillinctus 15ml po/tid

Neb.ipravent-8th hrly

Budecort-12th hrly

Tab-dolo 650mg po/tid

candid mouth plant l/A bd -2 weeks

Betadine gargle-3 times in a day

After intubation et culture was done it shows klebsiella pneumonia 

On the of 1-12-23

Att was started 

Serial chest x-ray before intubation (1-12-23)

After intubation on 1-12-23

Fever charting since day of 1 admission

On dec 6 patient is on-

IV fluids,RT feeds

Inj.Moxifloxacin,  cap.doxycycline, tab akt3,inj.clexane,inj.neurobion forte,nen.duolin and ipravent,inj norad,inj thiamine,et tube suctioning