Case history-02

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.

A 30 year old female came to the casualty with the chief complaints of cough since 20 days and SOB since 3-4 days.Patient a/a 20 days back.Then she developed cough which is insidious in onset and intermittent and 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, intermittent fever subsided on taking medications.

HISTORY OF PRESENT ILLNESS:-

SOB since 3-4 days which is insidious in onset and non-progressive grade 1or2.

No history of palpitation,sweating,nausea, vomiting.

PAST HISTORY:-

Not a k/c/o diabetes mellitus, hypertension,asthama,tb, epilepsy.

No similar complaints in the past.

PERSONAL HISTORY:-

Diet:mixed

Appetite:normal

Sleep:adequate

Bowel and bladder habits: regular

Addictions:no

FAMILY HISTORY:-

No H/O similar complaints in the family

TREATMENT HISTORY:-

No H/O previous treatment.

GENERAL EXAMINATION:-

Pt. Is c/c/c is moderately built and nourished.

Nopallor,icterus,cyanosis,clubbing,

lymphadenopathy and edema.

BP:120/80mm Hg

PR: 72per min

Temp:Afebrile

SPO2:96% at RA

GRBS: 102 mg%

SYSTEMIC EXAMINATION:-

RS:Left side- inframammary area ,infra axillary area infra scapular area are having inspiratory crepts.

Right side- infra mammary area ,infra scapulaar area infra axillary 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 organomegalay

CNS:Intact

PROVISONAL DIAGNOSIS:-

Viral pyrexia.

INVESTIGATIONS:-

Hemogram:

HB%-11.5

TLC-12500

PLATLET-4.9





FINAL DIAGNOSIS:

Viral Pneumonia

? LRTI

TREATMENT:-

DAY-1:

IVF-2NS,@75ml/hr.

Inj.optineuron 1amp in 100ml NS IV OD

Syp.ascoril 10mlPO BD

Tab.augmentin 635mg PO BD

Tab.paracetamol 650mg PO TID

Tab.pan40mg PO OD

NEB with budicort 12th hrly, duolin 8th hrly

Monitor vitals 4th hrly

DAY-2:

IVF - RL ,NS@75ML/HR

Syp.ascoril 10ml PO BD

Tab.augmentin 635mg PO BD

Tab.paracetamol 650mg PO TID

Tab.pan40mg PO OD

NEB with budicort 12th hrly, duolin 8th hrly

Tab.azithral 500mg PO OD

Inform SOS

DAY-3:

IVF - RL ,NS@75ML/HRp

Syr.ascoril 10ml PO 

Tab.augmentin 635mg PO 

Tab.paracetamol 650mg PO T

Tab.pan40mg PO 

NEB with budicort 12th hrly, duolin 8th hr

Tab.azithral 500mg PO 

Inform SOS.

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