feverprojr FUNGAL 45/F 202420301

 Fungal : 45 year old female 

date of admission 8/5/2024 

date of discharge 12/5/2024

ACUTE ON CHRONIC RESPIRATORY FAILURE WITH HYPOXIA SECONDARY TO LOWER RESPIRATORY TRACT INFECTION (COMMUNITY AQUIRED PNEUMONIA)

-CAVITATION IN LEFT APEX ? FUNGAL BALL CHRONIC ASPERGILLOSIS

-CORPULMONALE

-TRACTION BRONCHIECTASIS OF BOTH LUNGS

-H/O PULMONARY KOCHS 15 YEARS AGO

-K/C/O DM SINCE 10 YEARS HYPERTENSION SINCE 5 YEARS

Case History and Clinical Findings

PATIENT COMPLAINS OF SHORTNESS OF BREATH SINCE 6 DAYS

HOPI:-PATIENT WAS APPRENTLY ASYMPTOMATIC 6 DAYS AGO THEN SHE DEVELOPED SHORTNESS OF BREATH GRADE-III NYHA WHICH GRADUALLY PROGRESSED TO GRADE-IV NYHA SINCE 2 DAYS INSIDIOUS IN ONSET.

H/O 2 EPISODES OF VOMITING,GREENISH IN COLOUR,CONTAINED FOOD PARTICLES SINCE TODAY MORNING.

H/O COUGH +2-3 EPISODES NON PRODUCTIVE TYPE INITIALLY NOT ASSOCIATED WITH POST TUSSIVE VOMITING, LATER PRODUCTIVE WITH YELLOW SPUTUM.

NO H/O ,LOSS OF CONSCIOUSNESS,LOOSE STOOLS,CONSTIPATION,BURNINGMICTURITION,CHEST PAIN,PALPITATION.

H/O FEVER 1 DAY BACK FOR 3 DAYS HIGH GRADE, INTERMITTENT TYPE, RELIEVED ON MEDICATION

NO H/O HEMOPTYSIS, WEIGHT LOSS, LOSS OF APPETITE

H/O SIMILAR COMPLAINTS 15 YEARS AGO AND 8 MONTHS AGO FOR WHICH SHE WAS ADMITTED AND TREATED WITH ATT, INTERMITTENT CPAP, O2 SUPPORT, BRONCHODILATORS AND MUCOLYTICS.

K/C/O PULMONARY TUBERCULOSIS 15 YEARS BACK TOOK ATT FOR 6 MONTHS

K/C/O TYPE-2 DIABETES MELLITUS SINCE 10 YEARS ON T.SITAGLUIPTIN 50 MG + T.METFORMIN 500MG

K/C/O HYPERTENSION SINCE 6 YEARS ON T.AMLO-AT 5/50MG

PERSONAL HISTORY:-

APETITE-NORMAL

BOWEL AND BLADDER-REGULAR

ALLERGIES-NIL

ADDICTIONS-NIL

FAMILY HISTORY:-NOT SIGNIFICANT

GENERAL EXAMINATION:-

PATIENT IS CONSCIOUS,COHERENT,CO-OPERATIVE

NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY.

BILATERAL PEDAL EDEMA +, PITTING EDEMA

VITALS AT ADMISSION :

BP-150/100 MMHG

TEMP:-98.6

PR:-84BPM

RR:-24CPM

SPO2 - 56% @ RA

GRBS:-260MG/DL

SYSTEMIC EXAMINATION:-

CVS:-S1 S2 HEARD NO MURMURS

RS:- BILATERAL AIR ENTRY+; EXPIRATORY WHEEZE+ IN RIGHT MAMMARY, INFRACLAVICULAR, LEFT MAMMARY AREA; CREPITATIONS + IN B/L BASAL AREAS (MA, IAA, ISA)

PER ABDOMEN:-NO TENDERNESS

NO ORGANOMEGALY

CNS:-NO FOCAL NEUROLOGICAL DEFICITS NOTED

COURSE IN THE HOSPITAL

A 45 YEAR OLD FEMALE PATIENT, WHO IS A KNOWN DIABETIC, HYPERTENSIVE AND WITH HISTORY OF PULMONARY TUBERCULOSIS (15YRS AGO) WAS BROUGHT TO CAUALTY WITH C/O SHORTNESS OF BREATH SINCE 6 DAYS, GRADE III NYHA, EXACERBATED SINCE 2DAYS TO GRADE IV NYHA. THOROUGH CLINICAL EVALUATION WAS DONE AND NECESSARY INVESTIGATIONS WERE SENT.

CPAP SUPPORT WAS INITIATED, O2 SUPPLEMENTATION WAS GIVEN AND CONSERVATIVE MANGEMENT WAS STARTED.

AFTER TAKING BLOOD, URINE AND SPUTUM CULTURES WERE SENT AND IV ANTIBIOTICS WERE STARTED.

2DECHO WAS DONE WHICH SHOWED [(ECCENTRIC TR+) MODERATE TR+ WITH MILD PAH;TRIVIAL AR+, NO RWMA.NO AS/MS.NO MR ,EJECTION FRACTION=68%;RVSP-51MMHG, GOOD LV SYSTOLIC DYSFUNCTION, GRADE-I DIASTOLIC DYSFUNCTION, NO LV CLOT] &USG ABDOMEN WAS DONE WHICH SHOWED CHOLELITHIASIS(12MM), LEFT MILD PLEURAL EFFUSION, RIGHT GRADE 1 RPD CHANGES.

OUTSIDE CT SCAN SHOWED LEFT MODERATE AND RIGTH MILD PLEURAL EFFUSION, DEPTH MEASURING 3CVM AND 8CM ON LEFT &RUGHT RESPECTIVELY, CAVITATION IN LEFT APEX WITH DEPENDENT SOLID COMPONENT, PROBABLE FUNGAL BALL, E/O CYSTIC AND TRACTION BRONCHECTATIC CHANGES WITH FIBROSTREAKY OPACITIES IN BOTH LUNGS, LOSS OF LUNG VOLUME ON RIGHT SIDE.

PATIENT IS PROVISIONALLY DIAGNOSED WITH REACTIVATION OF TUBERCULOSIS/LRTI (?COMMUNITY ACQUIRED PNEUMONIA)

PULMONOLOGY OPINION WAS TAKEN FOR BRONCHOSCOPY AND BRONCHOALVEOLAR LAVAGE. BUT THE PATIENT AND HER ATTENDERS WERE NOT WILLING FOR THE SAID PROCEDURE AND REFUSED TO GIVE CONSENT AND WANT TO GET IT DONE ON FOLLOW UP.

DURING THE COURSE IN THE HOSPITAL, PATIENT HAD NO FEVER SPIKES, SHORTNESS OF BREATH REDUCED, O2 REQUREMENT REDUCED.

DURING THE COURSE OF STAY PATIENT WAS TREATED WITH IV ANTIBIOTICS, ANIFUNGALS, PPIS,ANTIPYRETICS, CORTICOSTEROIDS, DIURETICS, MUCOLYTICS, BRONCHODILATORS, EXPECTORANTS, OHAs AND OTHER SUPPORTIVE DRUGS.

DURING THE COURSE OF STAY IN THE HOSPITAL, PATIENT IMPROVED IN CONDITION. HENCE THE PATIENT IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH HOME OXYGEN SUPPORT (@2-4 LIT TO MAINTAIN SPO2 >92%)

Investigation

HBsAg-RAPID 09-05-2024 01:01:AM Negative

Anti HCV Antibodies - RAPID 09-05-2024 01:01:AM Non Reactive

HIV 1/2 RAPID:-NEGATIVE

BGT:- A POSITIVE

ABG 08-05-2024 09:39:PMPH 7.371PH 7.371PCO2 41.4PCO2 41.4PO2 46.1PO2 46.1HCO3 23.4HCO3 23.4St.HCO3 22.6St.HCO3 22.6BEB -1.3BEB -1.3BEecf -1.1BEecf -1.1TCO2 44.8TCO2 44.8O2 Sat 73.9O2 Sat 73.9O2 Count 17.9O2 Count 17.9

RBS ON 9/5/24 :-262 MG/DL

BLOOD UREA 09-05-2024 :-23 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 09-05-2024 01:00:AMSODIUM 138 mmol/LPOTASSIUM 3.9 mmol/L CHLORIDE 101 mmol/L

SERUM CREATININE 09-05-2024 01:00:AM :-1.0 mg/dl

LIVER FUNCTION TEST (LFT) 09-05-2024 01:00:AMTotal Bilurubin 2.39 mg/dl Direct Bilurubin 0.60 mg/dl SGOT(AST) 44 IU/L SGPT(ALT) 49 IU/LALKALINE PHOSPHATASE 207 IU/L TOTAL PROTEINS 8.9 gm/dl ALBUMIN 4.52 gm/dl A/G RATIO 1.03

BLEEDING TIME:-3 MIN

CLOTTING TIME:-4 MIN 30 SEC

APTT:-35 SEC

PT:-17

INR:-1.25

COMPLETE URINE EXAMINATION (CUE) 09-05-2024 01:00:AMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

HEMOGRAM:-(9/5/24)

HB:-14 GM/DL

TLC:-12,500 CELLS/CUMM

PCV:-44.3%

MCV:-87.6 FL

MCH:-29.3 PG

MCHC:-33.4%

RBC:-5.0 MILLION/CU MM

PLATELET COUNT:-2.9 LAKHS/CU MM

IMPRESSION:-NCNC WITH LEUCOCYTOSIS

FBS:-120 MG/DL

HBA1C:-6.8%

PLBS:-200MG/DL

HEMOGRAM:-(10/5/24)

HB:-14.6 GM/DL

TLC:-9200 CELLS/CUMM

PCV:-42.6%

MCV:-87.9 FL

MCH:-30.1 PG

MCHC:-34.2%

RBC:-4.85 MILLION/CU MM

PLATELET COUNT:-2.6 LAKHS/CU MM

LIVER FUNCTION TEST (LFT) 10-05-2024

Total Bilurubin 1.30 mg/dlDirect Bilurubin 0.35 mg/dlSGOT(AST) 42 IU/LSGPT(ALT) 48 IU/LALKALINE PHOSPHATASE 178 IU/LTOTAL PROTEINS 7.6 gm/dlALBUMIN 3.8 gm/dlA/G RATIO 1.04

2D ECHO DONE ON 9/5/24:-

-(ECCENTRIC TR+) MODERATE TR+ WITH MILD PAH;TRIVIAL AR+

-NO RWMA.NO AS/MS.NO MR

-EJECTION FRACTION=68%;RVSP-51MMHG

-GOOD LV SYSTOLIC DYSFUNCTION

-GRADE-I DIASTOLIC DYSFUNCTION

-NO LV CLOT

-IVC SIZE(1.50CMS) COLLAPSING

-SCLEROTIC AV

-NO AS/MS

USG ABDOMEN WAS DONE ON 09/05/24

(SUBOPTIMAL SCAN)

IMPRESSION :

CHOLELITHIASIS (12MM HYPERECHOIC FOCUS)

LEFT MILD PLEURAL EFFUSION

RIGHT GRADE 1 RPD CHANGES

CT SCAN (OUTSIDE)

LEFT MODERATE AND RIGTH MILD PLEURAL EFFUSION, DEPTH MEASURING 3CVM AND 8CM ON LEFT &RUGHT RESPECTIVELY.

CAVITATION IN LEFT APEX WITH DEPENDENT SOLID COMPONENT, PROBABLE FUNGAL BALL

E/O CYSTIC AND TRACTION BRONCHECTATIC CHANGES WITH FIBROSTREAKY OPACITIES IN BOTH LUNGS.

LOSS OF LUNG VOLUME ON RIGHT SIDE

Treatment Given(Enter only Generic Name)

INJ.LASIX 40MG IV/TID X 5 DAYS

INJ.AUGMENTIN 1.2 GM/IV/BD X 5DAYS

INJ.PAN 40MG IV/OD

INJ.NEOMOL 1GM/IV/SOS

INJ.HYDROCORTISONE 100MG IV/SOS

INJ.HAI/SC/TID

T.AZITHROMYCIN 500 MG PO/OD X 4DAYS

T.ITRACONAZOLE 200MG PO/BD X 5DAYS

T.PULMOCLEAR PO/BD X 2DAYS

T.SITAGLIPTIN 50MG + T.METFORMIN 500MG PO/OD

SYP.ASCORIL-LS 10ML/PO/TID

NEB WITH DUOLIN 6TH HRLY

BUDECORT 8TH HRLY

MUCOMIST 6TH HRLY

INTERMITTENT CPAP

Advice at Discharge

HOME OXYGEN

TAB AUGMENTIN 625MG PO/BD FOR 2 DAYS 8AM AND 8 PM

TAB ITRACONOZOLE 200 MG BD AT 8 AM AND 8PM FOR 10 DAYS

TAB.DYTOR PLUS 10/50MG /PO/OD AT 8 AM TO CONTINUE

TAB TELMA 20MG/PO/OD AT 8 AM TO CONTINUE

TAB PAN 40MG PO/OD X 1 WEEK BEFORE BREAKFAST

T.AZITHROMYCIN 500 MG PO/OD AT 2PM X 1 DAY

T.PULMOCLEAR PO/BD AT 8 AM AND 8 PM X 5 DAYS

T.SITAGLIPTIN 50MG + T.METFORMIN 500MG PO/OD BEFORE BREAKFAST TO CONTINUE

TAB REJUNEX CD3 PO/OD AT 2 PM X 15DAYS

SYP.ASCORIL-LS 10ML/PO/TID AT 8 AM ,2PM AND 8 PMX 1 WEEK

NEB WITH DUOLIN 12TH HRLY

BUDECORT 12TH HRLY

MUCOMIST 12TH HRLY

HOME O2 SUPPORT @ 2-4 LIT TO MAINTAIN SPO2 >92%