Concluded Case

Patient age 75 years male chronic smoker from last 40 years with no h/o diabetes, hypertension, epilepsy and tuberculosis presented with c/c/o sob,sweating, gen body weakness on 24 -4-19(23:40hrs) On arrival his vitals Bp :180/100 mm Hg Temp: 99.5 f Spo2 :80% Pulse by pulse oxymeter: 102 / min O/a his examination: Cns : conscious and oriented Gcs:15/15 Cvs: s1 s2 audible no murmur heard Chest : tachypnoea+ B/l crepts++ P/a: mild tenderness in epigastrium region No significant organomegally felt Constipation +nt Passing urine adequately For the same complaints patient visited a pulmonologist on 19-4-19 and was investigated for routine blood tests which revealed hb: 13.7, tlc: 14720 , dlc: 80,18,01,01,00. Rbs 115 Cxr: pl calcification Bp 160/70 , spo2 84 % And was advised with Tab pulmocef 200 bd Cap esomperazole od es Tab derriphyllin r 300 bd Foracort forte rc bd Tab ribhist am bd Syrup cremaffin 2 tsf Hs Despite all this t/t his condition deteriorated and he landed up with the same problems in our hospital with above mentioned complaints. For the initial relief he was prescribed with o2 inhalation, nebulization with budecort and duolin and for his hypertensive status he was given inj lasix 2ml i/v stat with i/v corticosteroid Cort s 100 mg. He was investigated for cardiac causes for which ecg was done that revealed tachycardia (pic 1) His blood investigations revealed septicaemia , hyperuricemia. (Pic 2) On the behalf of his cbc report he was also added up with i/v Antibiotic augmentin 1.2 gm tds with 50 ml ns. His cxr pa view was done next morning which showed left lower lobe consolidation and left sided pleural effusion (pic 3). Patient was getting relief from above treatment but he was not maintaining spo2 if taken off from o2. On 26-4-19 his sputum for Afb was done which was -ve . His TLC count improved from day. And his family was counselled for the need of hrct to rule out ild or other d/s as ct is not available in town. On 27/4/19 his TLC further decreased to 12000 his hrct chest was done that revealed the findidings as stated in pic 4 Ie: centrilobulor emphysema with bullous lesion in b/l lung field. Consolidation with Swiss cheese appearnce In left upper lobe. B/l plural effusion Left lower lobe passive atelectasis. Few scattered nodules in rt upper lobe and rt middle lobe. Patient was advised to shift their patient to higher centre but due to financial conditions they are unable to shift him and wants to get their patient treated at our centre or to take him home. What can be the line of management in this case..??? And what further investigations we can opt for. Thanks

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Concluded answer

Well managed in available conditions Pleural tapping will give some more idea to r/o malignancy it is suspicious in lt lower lobe Ecg shows tachycardia xray chest shows density lt lower lobe with bilateral pleural effusion and emphsematous changes and fibrotic strands as pt is chr smoker lung vital capacity is vary poor and hence he is hypoxic despite oxygenation Thiugh Abg not available but it looks to be obviously respiratory acidosis and should be treated Antibiotics given are responding hence continue Diuretics to be continued Even there is PAH as pulmonary vessels are dilated and prominent Keep your fingers crossed regarding prognosis

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Considering patient's Clinicoradiological status, basic investigations like sputum examinations in detail, 2 d echo would be helpful. Considering smoking history and changes of COPD emphysema,Adding Tiotropium can help him. Bronchoscopy and therapeutic BAL can help in reliving intraluminal obstruction . Diuretics would be helpful in improving bil pl effusion if transudate. If possible send sputum/ BAL for culture sensitivity test. Continue higher antibiotics, bronchodilators, mucolytics ,etc as per availability and cost effectiveness.

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Well managed in available conditions Pleural tapping will give some more idea to r/o malignancy it is suspicious in lt lower lobe Ecg shows tachycardia xray chest shows density lt lower lobe with bilateral pleural effusion and emphsematous changes and fibrotic strands as pt is chr smoker lung vital capacity is vary poor and hence he is hypoxic despite oxygenation Thiugh Abg not available but it looks to be obviously respiratory acidosis and should be treated Antibiotics given are responding hence continue Diuretics to be continued Even there is PAH as pulmonary vessels are dilated and prominent Keep your fingers crossed regarding prognosis

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b/l destroyed lung field with bullae and pleural effusions ECG shows S Tachy with Right Atrial Abnormality ABG not visible

Abg is not available in town sir
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ADVISABLE... 1. SPUTUM. EXAM 2. ECHO 3. BRONCHOSCOPY 4. DIURETIC

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