A 80 year old male with left upper lobe pneumonia (CAP)with hypertension and hematemesis




Patient came to OPD with complaints of SOB since 3 days and abdominal distension since 3 days (prior to admission).

HOPI: Patient was apparently asymptomatic 3 days back (prior to admission),then he developed breathlessness (Grade -3 acc to NYHA ),which is sudden in onset,aggravated on supine position, orthopnea present ,PND present.
H/O cough with sputum,blood stained ,moderate quantity.
H/O low grade fever ,diurnal variation present ,more during night associated with sweating,no h/o cold.
H/O chest heaviness ,non radiating and now relieved.
H/O B/L Pedal edema upto ankles since 3-4 years,relieves on activity.
H/O abdominal distension since 3 days ,insidious in onset and gradually progressive. NO H/O pain abdomen, loose stools ,constipation, regurgitation.
H/O burning micturition present and dribbling of urine present
H/O urge continence,no h/o stress incontinence.
PAST HISTORY:
k/c/o hypertension 4 years back ,on regular medication (unknown)
N/k/c/o diabetes mellitus, CVA,CAD,Thyroid disorders, epilepsy,asthma.
H/O Anuria 15 years back underwent some urological procedure ,h/o hydrocele surgery, h/o lipoma (on thigh)surgery

 PERSONAL HISTORY:
Diet :mixed
Appetite:normal
Bowel and bladder movements:regular
Occasional toddy drinker

 GENERAL EXAMINATION:
BP:100/60mmHg
PR:80bpm
RR:18cpm
Temp:98.4°F
Spo2:96@RA
GRBS:141mg/dl

 SYSTEMIC EXAMINATION:
CVS:S1 S2 heard
         PSM present
RS: BAE +
       Basal crepts present
P/A : soft and non tender
CNS: No neurological deficits

PROVISIONAL DIAGNOSIS:
Left upper lobe pneumonia (CAP)
Pre renal AKI (Resolving)
Heart failure mid range ejection fraction (50%)
Chronic AF with FVR
Hypertension 
Hematemesis 

INVESTIGATIONS:

Upper GI Endoscopy- clean based antral gastric ulcer ,Forrest type 3 ulcer


USG ABDOMEN:


HRCT 








     











Treatment:
1.Intermittent CPAP
2.IV FLUIDS DNS @50ml/hr
3.salt restriction <2gm /day
4.T.AMOXICLAV 625mg PO/BD
5.INJ.TRANEXA 1gm IV/SOS
6.INJ.VIT-K 10mg IV/OD
7.T.CARVEDILOL 3.125mg PO/BD
8.T.DYTOR PLUS  10/50 PO/OD
9.T.GRYLLINCTUS 10ml PO/TID
10.ZYTEE GEL for L/A
11.INJ.PAN 80mg IV/BD



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