Patient with cough and SOB

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 is welcome.



CASE:
A 30 year old female came in to the casualty with chief complaints of cough since 20 days and sob since 3-4 days.
Patient is apparently asymptomatic 20 days back when she developed cough which is insidious in origin and is intermittent and is associated with expectoration which is whitish in colour and scanty in amount. It associated with right sided chest pain which is sharp pricking type of pain and increased on inspiration. 
It is also associated with fever 20 days back, low grade intermittent fever which subsided on taking medications. 
H/o SOB since 3 to 4 days which is insidious in onset and non progressive, ( grade 1 or 2).
No h/o palpations, sweating, nausea and vomiting. 

PAST HISTORY:
Not a know case of diabetes, HTN, asthma, TB, epilepsy. 
No similar complaints in the past. 

PERSONAL HISTORY:
DIET: mixed, 
APPETITE: normal, 
SLEEP: adequate, 
BOWEL AND BLADDER MOVEMENTS: regular, 
ADDICTIONS: none. 

GENERAL EXAMINATIONS:
Pt is conscious, coherent, cooperative with moderate nourishment and moderate built. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 
VITALS:
BP: 120/80mmHg. 
PR: 72/min. 
RR: 18 CPM 
TEMP: afebrile. 
SPO2: 96% RA
GRBS: 102 mg%

SYSTEMIC EXAMINATION:
RS: 
Left side- Inframammary area, infra-axillary area, infra-scapular area are having inspiratory crepts. 
Right side - Inframammary area, infra axillary area, infra-scapular area are having inspiratory crepts and wheeze. 
CVS: S1 and S2 heard. 
P/A: soft, non tender, no palpable masses, hernia orifices clear, no free fluid, no organomegaly. 
CNS: no focal deformities.

PROVISIONAL DIAGNOSIS : 
      ? VIRAL PNEUMONIA

INVESTIGATION:
1) Hemogram: HB: 11.5 mg/dl,  TLC: 12500,  PC: 4.9 lakh

2) Serum Electrolytes:  Na: 138 mEq/L, K: 5.5 mEq/L, Cl: 98 mEq/L.
                                    
3) X-RAY: 
    



4) HRCT: 
          a) Images:


 
        b) Report:

5) ECG:

6) Bronchoscopy:
         - Vocal cords, trachea, carina are normal.
         - Left bronchus - Lower lobe secretions present, mucosa normal.
         - Right bronchus - Lower and middle lobe secretions present, mucosa normal.











FINAL DIAGNOSIS: Viral pneumonia.
- MEDIASTINAL LYPHADENOPTHY WITH KOCH'S LYMPHOMA
PLAN OF TREATMENT:

DAY 0

VITALS:
BP: 120/80 MMHG
PR: 90 BPM
TEMP: AFEBRILE

TREATMENT GIVEN:
1. IVF - 2 NS, @ 75 ML/ HR. 
2. SYP ASCORIL 10 ML PO BD. 
3. TAB AUGMENTIN 625 MG PO BD.
4. TAB PCM 650 MG PO TID.
5. TAB PAN 40 MG PO OD.
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY 8. MONITOR VITALS 4TH HRLY.

DAY 1: 

VITALS:
BP: 100/80 MMH
PR: 76 BPM
TEMP: AFEBRILE.

TREATMENT GIVEN:
1. IVF - RL, NS, @ 75 ML/ HR.
2. SYP ASCORIL 10 ML PO BD. 
3. TAB AUGMENTIN 625 MG PO BD.
4. TAB PCM 650 MG PO TID.
5. TAB PAN 40 MG PO OD. 
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY. 
7. TAB AZITHRAL 500 MG PO OD.

DAY 2: 

VITALS:
BP: 110/80 MMHG.
PR: 100 BPM.
TEMP: AFEBRILE.

TREATMENT GIVEN:
1. IVF - RL, NS, @ 75 ML/ HR.
2. SYP ASCORIL 10 ML PO BD.
3. TAB AUGMENTIN 625 MG PO BD.
4. TAB PCM 650 MG PO TID. 
5. TAB PAN 40 MG PO OD.
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY.
7. TAB AZITHRAL 500 MG PO OD.



DAY 3:

VITALS:-
BP: 110/80 mmHg
PR: 90 BPM
TEMP: afebrile 

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr.
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD.
4. Tab pcm 650mg po tid.
5. Tab pan 40 mg po od.
6. Neb with budecort 12th hrly, duolin 6th hrly.



DAY 4

VITALS:
BP:100/80 mmhg. 
PR: 95 BPM. 
TEMP: afebrile. 

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD.
3. Tab augmentin 625 mg po BD.
4. Tab pcm 650mg po SOS.
5. Tab pan 40 mg po od.
6. Neb with budecort 12th hrly, duolin 6th HRLY.


DAY 5

VITALS:
BP:110/80 mmHg
PR:90 BPM
TEMP: febrile to touch (99.1°F).

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th hrly. 


DAY 6:
VITALS:
BP: 110/80 MMHG
PR: 90
TEMP: AFEBRILE 

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th HRLY. 

DAY 7:

VITALS:
BP: 110/90MMHG
PR: 100 BPM
TEMP: AFEBRILE. 

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th HRLY. 

DAY 8:

VITALS:
BP: 110/70 MMHG
PR: 80 BPM
TEMP: AFEBRILE. 

TREATMENT GIVEN:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th HRLY. 




Discharge summary:

Discharge Date:
Ward:GM Unit:4 

Name of Treating Faculty 
Dr. Prakash (intern).
Dr. Lakshman (intern).
Dr. Supraja (intern).
Dr. Akshara (intern).
Dr. Sowmya (intern).
Dr. Arun (intern).
Dr. Raveen ( PG 2 ).
Dr. Nikitha (PG - 3).
Dr. Vaishnavi (PG - 3).
Dr. Hareen ( SR ).
Dr. Arjun ( AP ).
Dr. Rakesh biswas ( HOD )

Diagnosis:? VIRAL PNEUMONIA. 
?  MEDIASTINAL LYPHADENOPTHY WITH KOCH'S LYMPHOMA. 

Case History and Clinical Findings:
 A 30 YEAR OLD FEMALE CAME TO THE CASUALITY WITH THE CHIEF COMPLAINTS OF COUGH SINCE 20 DAYS AND SOB SINCE 3 TO 4 DAYS . PT IS APPARENTLY ASYMPTOMATIC 20 DAYS BACK. THEN SHE DEVELOPED COUGH WHICH IS INSIDIOUS IN ONSET AND INTERMITTENT , ASSOCIATED WITH EXPECTORATION WHICH IS WHITISH IN COLOUR AND SCANTY IN AMOUNT . IT IS ASSOCIATED WITH RIGHT SIDED CHEST PAIN WHICH IS SHARP PRICKING TYPE OF PAIN AND INCREASED ON INSPIRATION . IT IS ALSO ASSOCIATED WITH FEVER SINCE 20 DAYS . LOW GRADE , INTERMIITENT FEVER SUBSIDED ON TAKING MEDICATIONS. H/O SOB SINCE 3 TO 4 DAYS WHICH IS INSIDIOUS IN ONSET AND NON PROGRESSIVE GRADE 1 OR 2 . NO H/O PALPITATIONS, SWEATING, NAUSEA, VOMITING . 
PAST HISTORY: NOT K/C/O DM, HTN, ASTHMA, TB, EPILEPSY . NO SIMILAR COMPLAINTS IN THE PAST.
PERSONAL HISTORY: 
DIET:MIXED APPETITE: NORMAL SLEEP : ADEQUATE BOWEL AND BLADDER HABITS; REGULAR ADDICTIONS; 

NO O/E: PT IS C/C/C WITH MODERATELY BUILT AND NOURISHED . NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHHY , EDEMA . 
BP- 120/80 MM OF HG 
PR- 72/MIN 
TEMP- AFEBRILE 
SPO2- 96% AT RA 
GRBS : 102 MG% 
SYSTEMIC EXAMINATION : 
RS- LEFT SIDE : INFRAMAMMMARY AREA, INFRA AXILLARY AREA , INFRA SCAPULAR AREA ARE HAVING INSPIRATORY CREPTS RIGHT SIDE : INFRAMAMMMARY AREA , INFRAAXILLARY AREA , INFRASCAPULAR AREA HAVING INSPIRATORY CREPTS AND WHEEZE . 
CVS: S1 S2 HEARD. 
P/A: SOFT, NON TENDER , NO PALPABLE MASSES , HERNIAL ORIFICES CLEAR, NO FREE FLUID , NO ORGANOMEGALY . 
CNS - INTACT 

Investigation :
HEMOGRAM: HB - 11. 5 TLC- 12500 PLT- 4.9

Treatment Given(Enter only Generic Name)
 ON DAY 0: 
1. IVF - 2 NS, @ 75 ML/ HR. 
2. SYP ASCORIL 10 ML PO BD. 
3. TAB AUGMENTIN 625 MG PO BD. 
4. TAB PCM 650 MG PO TID. 
5. TAB PAN 40 MG PO OD. 
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY 8. MONITOR VITALS 4TH HRLY. 

DAY 1: 
1. IVF - RL, NS, @ 75 ML/ HR. 
2. SYP ASCORIL 10 ML PO BD. 
3. TAB AUGMENTIN 625 MG PO BD. 
4. TAB PCM 650 MG PO TID. 
5. TAB PAN 40 MG PO OD.
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY.
7. TAB AZITHRAL 500 MG PO OD. 

DAY 2: 
1. IVF - RL, NS, @ 75 ML/ HR. 
2. SYP ASCORIL 10 ML PO BD. 
3. TAB AUGMENTIN 625 MG PO BD. 
4. TAB PCM 650 MG PO TID .
5. TAB PAN 40 MG PO OD. 
6. NEB WITH BUDECORT 12 TH HRLY , DUOLIN 8TH HRLY .
7. TAB AZITHRAL 500 MG PO OD. 

DAY 3:
1. IVF - ns, rl @ 75ml/hr.
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD.
4. Tab pcm 650mg po tid.
5. Tab pan 40 mg po od.
6. Neb with budecort 12th hrly, duolin 6th hrly.

DAY 4:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th hrly.

DAY 5:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th hrly.

DAY 6:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th hrly.

DAY 7:
1. IVF - ns, rl @ 75ml/hr. 
2. Syp ascoril 10 ml po BD. 
3. Tab augmentin 625 mg po BD. 
4. Tab pcm 650mg po SOS. 
5. Tab pan 40 mg po od BBF. 
6. Neb with budecort 12th hrly, duolin 8th hrly.

 Advice at Discharge: 
1. TAB. MVT PO OD FOR 7 DAYS. 
2. TAB PAN 40 MG PO OD FOR 5 DAYS.
3. SYP GRILLINCTUS 10 ML PO BD. 
4. TAB PCM 650 MG PO BD FOR 5 DAYS.

Follow Up:
Review after 4 days with reports or Review SOS.











Popular posts from this blog

Patient with SOB and pedal edema

Image
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 is welcome. 60 yr old female , resident of miryalguda , having 4 children. Pt used to work as ayamma in govt hospital. She stopped working 5 years ago due to jaundice and abdominal distension . Pt is chronic alcoholic - 90-180 ml alcohol intake daily ( whiskey ), Non smoker . History of one episode of seizures 8 yrs ago when they visited temple in yadgiri gutta - As she stopped alcohol bcoz she was going to temple. No other seizure episodes till date. 5 years ago pt had h/o abdomin
Read more

A 42 year old with multiple health events

 I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  You can find the entire real patient clinical problem in this link here.. https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Following is my analysis of this patient's problem: The problems in order of priority I found are    Migraine with aura  Sleeplessness Breathing difficulty Swelling Multiple falls 1. Migraine with aura associated with left sided decreased function ONSET: Sudden  DURATION: Since 2 years of age Gradually progressive ASSOCIATED SYMPTOMS :  Numbness of left hand and left face felt like someone was pouring ice water over the  cheek and also feeling of falling and spinning at night. Preceded by AURA associated with transient loss of v
Read more