Case
advice for treatment

Age: 89
Sex: Male
Race: indian

History
History of present illness:
admitted in hospi.. on June 2 as a case of acute pulmonary arrest after vomitting & sudden SOB and AMS with renal tumor SIP ..

Medical History:
Tumor on rt idney for last 4 years believed to be malignant but dormant...

Weak in health but stable and discharging
normal functions...

Past surgical history:
None

Allergies:
None

Medications:
On ventillator, IVF, dopamine drops and antibiotics....

Reports suggest aspiration pneumonitis, septisemia and ARF ...

Treated along conservative line of treatment...

Family history:
He has been a senior federal govt executive, retired in 1976.

Has well settled compact family. Wife expired 5 years back due to pulmonary failure..

Social history:
Longevity in family , his parents lived healthy life up to 90's without heart / kidney problems.. but had respiratory problems...


Physical Exam
General:
Gen condition : presently low
otherwise normal for
his age.
Regular with YOGic exercises.
Height : 5' 7"
Weight : 64 Kg.
B.P. 80/ 60 with Ionotropic support
P.R. 96 Resp rate 22 SPO2 92
Chest : Bilateral clear with occasional crept.
CVS normal

Temperature:
Normal

Heart rate:
60-70

Blood pressure:
100/60 but varying over the day upto 120/70

Respiratory rate:
22 per minute

Oxygen saturation:
80-96%

Head, ears, eyes, nose & throat:
Head, ears, eyes responding when spoken to.
Sputum has to be extracted but is improving interms of rate output.
Oxygen supply through tube in mouth and there is soreness.

Neck:
Normal

Chest:
no congestion, abnormality

Cardiovascular:
N S1S2



Abdomen:
normal

GU:
normal

Rectal:
normal

Neurological:
drowsy, semi-consious, pupil bilateral, NSNR, planter bilateral flexus

Skin:
normal

Radiology:
right kidney shows a mass of 64mm on lower pole

Other:
ABG pH 7.4
PCO2 44.4
PO2 51.6
Na+ 166
K+ 3.61
HCO3 28
BE 3.5

Pathology:
Hb 13.2 TLC 14800 DLC C 80
L 8
Creatinim 2.4
RBS 202


Problems:
B.P not maintained.
Consciousness level not improving

Plan of treatment:
gradually weaning from ventilator and external O2 supply to be decreased.

Endotrachial tube to removed

B.P to be maintained without support

Overall general condition to improve

Results of treatment:
consciousness better but still drowsy.

B.P maintained with support only.

genral condition fair






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