A 35Y/M WITH c/o dry cough , SOB grade II, nausea and with h/o hemoptysis.

April 8th, 2022
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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


A 35 year male, driver by occupation, came with complaints of dry cough, grade II sob, nausea and with h/o hemoptysis.

History of presenting illness: 
A 35 year male with h/o dry cough, episode of hemoptysis, low grade fever, grade II sob (17/3/22), 
was admitted at yashodha hospital on 17/3/22 and diagnosed as:
- AKI on CKD - was dialysed 4times and advised for maintenance HD.
- LRTI - B/L non homogeneous opacities on xray - edema with superadded infections (on HRCT chest).
- Sepsis MODS.
then patient was discharged on 28/3/22.
CREATININE- 11   @admission
                          - 9   @discharge
USG - grade II RPD, CMD near complete lost, 
          - size - 9X3cm (Right)
                     - 8X3cm (Left)
2D ECHO- LV RWMA, EF:42%
Pt was asked to come for review after 1 week but pt didn't do due to personal reasons and came here for MHD.
presently c/o dry cough +, SOB grade II, Nausea +,
 hemoptysis  subsided.
No c/o reduced urine output, pedal edema , facial puffiness.

OUTSIDE INVESTIGATIONS: 
S.C3 AND C4 - NORMAL, 
ANTI GBM - NEGATIVE
ANCA - C, P-ANCA - NEGATIVE
CUE: ALB 3+, 24HR PROTEIN - 1.26gms, RBC - 15-20/hpt
ANA - NEGATIVE,  RENAL BIOPSY L.M Chronic tubulointerstitial inflammation.
comorbidities- Denovo HTN ( diagnosed 20days ago), non DM,  non CAD.
BAL fluid - 
AFB - NEGATIVE, 
C/S - No growth, 
fungal c/s - candidia albicans sensitive to voriconazole, flucanozole, capsi fungin , micofungi
PAN fungal DNA - POSITIVE
DNA QUALITATIVE:
Aspergillus niger - low positive
Aspergillus fumigatus, flavus - negative
Aspergillus mucoralesps - negative
Mycobacterium - negative





PAST HISTORY:
N/k/c/o DM , BA, EPILEPSY.

PERSONAL HISTORY:
HABITS: OCCASIONAL TOBACCO USE
He follows a mixed diet. 
Appetite -Normal,
Bladder movements- normal 
Bowel movements- Normal . 
Sleep- Adequate.

FAMILY HISTORY: No significant family history.

GENERAL EXAMINATION : 
patient is conscious ,coherrent, co operative and well oriented to surroundings. He is moderately built and nourished. 
Mild Pallor ,no cyanosis, no icterus, no lymphadenopathy. 








Vitals:
Temperature: 99.8
Pulse rate: 112 beats / min.
 Respiratory rate: 36 cycles / min.
 Bp: 220/140 mmhg
Spo2: 94@RA
Grbs: 104mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD

INVESTIGATIONS:
(8/4/22)
RBS-90MG/DL
HB-9.8
TLC-11,500 (87%N)
PLT-2.67

CUE: ALB - +, SUGARS - NIL, RBC - NIL

ABG: PH: 7.32, PO2: 79.1, PCO2: 13.6, HCO3: 6.9, ST.HCO3: 11.4, O2 sat: 93.5.

LFT: TB-2.44,DB - 0.56, AST -13, ALT- 10, ALP- 236, T.P- 6.2, ALB- 3.42, A/G: 1.23.

RFT- UREA: 182, CREAT: 8.7, URIC ACID: 9.4, Ca: 9.9, PO4: 7.2, Na: 139, k: 4.5, cl: 105.

SEROLOGY: NEGATIVE.

(9/4/22)
HB-9.6
TLC-8,800 (78%N)
PLT-2.55

ABG: PH: 7.49, PO2: 73.1, PCO2: 29.5, HCO3: 22.7, ST.HCO3: 24.3, O2 sat: 94.6.

LFT: TB-2.90, DB - 0.63, AST -12, ALT- 9, ALP- 221, T.P- 5.9, ALB- 3.51, A/G: 1.15.

RFT- UREA: 125, CREAT: 6.2, URIC ACID: 6.3, Ca: 9.9, PO4: 5.5, Na: 144, k: 3.7, cl: 103.


(10/3/22)
HB- 10.3
TLC- 12,000 (78% N)
PLT- 2.94

RFT- UREA: 151, CREAT: 7.5, URIC ACID: 7.6, Ca:8.0, Po4: 7.0, Na: 140, k: 4.0, cl: 9.8

ABS EOSINOPHIL COUNT: 240


(11/3/22)
HB: 9.6
TLC: 10,300 (83%N)
PLT: 2.78

RFT- UREA: 91  CREAT: 5.1  URIC ACID: 4.6  Ca: 10  Po4: 4.9   Na: 146  k: 3.9  cl: 97

FERRITIN- 889.7 ng/ml

(12/3/22)
HB: 9.7
TLC: 11,000 
PLT:  2.97

RFT- UREA:133  CREAT:6.4  Na: 140  k: 3.9  cl: 97

SR.IRON: 79

                







































DIAGNOSIS: 
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

TREATMENT:
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT  INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV  75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F

-----------------------------------------------------------

SOAP NOTES:
(9/4/22)
S:
 patient has c/o Dry cough, SOB reduced, nausea -
O:
BP- 180/110mmhg
PR- 110bpm
RR - 30cpm
spo2 - 96%@RA
Temp - afebrile
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:
On urea creatinine
8/4/22 182 8.5
9/4/22 125 6 2


A:
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

P:
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV 75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F)

-----------------------------------------------------------

(10/4/22)
S:
 patient has c/o Dry cough, SOB reduced, nausea -
O:
BP- 170/110mmhg
PR- 92bpm
RR - 28cpm
spo2 - 96%@RA
Temp - afebrile
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:
On urea creatinine
8/4/22 182 8.5
9/4/22 125 6 2
10/4/22 157 7.5

A:
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

P:
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV 75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F)

---------------------------------------------------------

(11/4/22)
S:
 patient has c/o Dry cough, SOB reduced, nausea -
O:
BP- 160/100mmhg
PR- 86bpm
RR - 26cpm
spo2 - 96%@RA
Temp - afebrile
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:
On urea creatinine
8/4/22 182 8.5
9/4/22 125 6 2
10/4/22 157 7.5
11/4/22 151 7.5

A:
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

P:
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV 75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F)
17.INJ AUGMENTIN 0.6MG IV BD
18 TAB AZITHRO 500mg PO OD
19.TAB SHELCAL PO OD

-----------------------------------------------------------------

(12/4/22)
S:
 patient has c/o Dry cough, SOB reduced, nausea -

O:
BP- 140/80mmhg
PR- 82bpm
RR - 23cpm
spo2 - 96%@RA
Temp - afebrile
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:
On urea creatinine
8/4/22 182 8.5
9/4/22 125 6 2
10/4/22 157 7.5
11/4/22 151 7.5
12/4/22 91 5.1

A:
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

P:

Planning for BAL ( BRONCHOALVEOLAR LAVAGE)
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV 75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F)
17.INJ AUGMENTIN 0.6MG IV BD
18 TAB AZITHRO 500mg PO OD
19.TAB SHELCAL PO OD
20.INJ PIPTAZ 2.25 GM IV BD

-------------------------------------------------------

(13/4/22)
SOAP NOTES 
ICU BED NO 3
S:
C/o fever yesterday night 
 Decreased cough , SOB reduced, 1 episode of vomiting today morning 

O:
BP- 140/80mmhg
PR- 88bpm
RR - 24cpm
spo2 - 96%@RA
Temp - afebrile
CVS: S1S2 heard, Apex 5th ICS, 1/2 inch lateral to mid clavicular line.
RS: BAE+, B/L crepts +
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:
On urea creatinine
8/4/22 182 8.5
9/4/22 125 6 2
10/4/22 157 7.5
11/4/22 151 7.5
12/4/22 91 5.1
13/4/22 90 4.8

A:
CHRONIC RENAL FAILURE (? CHRONIC TUBULO INTERSTITIAL DISEASE)
? FUNGAL PNEUMONIA (? RESIDUAL PNEUMONIA)
? CARDIOGENIC PULMONARY EDEMA 2° to HFpEF(2° to HTN)
 TYPE 1 RESPIRATORY FAILURE, HTN +

P:
Dialysis done on 12/4/22 at 4 pm 
BAL SAMPLE SENT FOR CULTURE AND CYTOLOGY INVESTIGATIONS 
1) INJECTION LASIX 40 MG IV TID TAB.
2)TAB. PAN 40MG PO/OD 
3)TAB. ZOFER 4 MG PO/BD 
4)TAB.NODOSIS 500 MG PO/TI D 5)NEBULIZATION .IPRAVENT&BUDECORT INH BD
6)SYRUP GRILLINCTUS 10 ML PO/TID
7)TAB.MONTEK -LC PO /BD
8)INJ. EPO 4000IU S.C WEEKLY ONCE
9)IN.IRON SUCROSE 200MG +100ML NS WEEKLY ONCE 
10) T.NICARDIA 20MG PO BD
11) T.ARKAMINE 0.1MG PO BD
12)TAB.CARDIVAS 3.125MG PO /BD
13)TAB.ECOSPRIN-AV 75/20MG PO/HS
14)I/O CHARTING,TEMP CHARTING
15)TAB.DOLO 650 MG PO/SOS (IF FEVER )
16)INJ.NEOMOL 1GM IV /SOS (IF FEVER >101°F)
17.INJ AUGMENTIN 0.6MG IV BD
18 TAB AZITHRO 500mg PO OD
19.TAB SHELCAL PO OD
20.INJ PIPTAZ 2.25 GM IV BD

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