Case 3

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A 30 year old female patient came to the casuality with cough since 20 days and shortness of breath since 4 days back. 

History of present illness:

-Patient was apparently asymptomatic 20 days back and the cough is insidious on onset and intermittent and associated with expectoration which is whitish in colour . 

-Cough is associated with fever which is low grade and intermittent. 

-And also associated with rightsided chest pain which is sharp pricking type. 

-Patients complains of shortness of breath since 4 days and is of non progressive. 

History of past illness:

-No similar complaints in the past. 

-There is no history of diabetes, hypertension, asthma, tuberculosis and epilepsy. 

Personal history:

Diet- Mixed.

Apetite - Normal. 

Sleep-adequate. 

Bowel and bladder movements - Regular. 

Addictions -No. 

Family history:

No history of such complaints in the family. 

General examination:

Patient is cooperative, coherent and conscious. 

He is well oriented to time, place and person.

-Physical examination-

No pallor. 

No ecterus. 

No cyanosis . 

No clubbing . 

No generalised lympadenopathy and

No oedema. 

Vitals-

           Blood pressure-130/70mm of hg.

           Pulse pressure-72/min

           Respiratory rate-18/ min

            Spo2-96% at room air. 

-Systemic examination:

Circulatory system-

        Chest wall is bilateral symmetrical. 

        No visible pulsations, engorged veins, scars. 

Respiratory system- 

        Dysapnea  is present. 

        Having inspiratory crepts and wheeze. 

        Position of trachea is central. 

        Breathe sounds are vesicular.

         Adventitous sounds rhonchi and rales. 

Per abdominal

         Abdomen is smooth and nontender. 

         Bowel movements are heard. 

         No palpable mass or free fluid. 

Auscultation:

         S1 and S2 are heard. 

Central nervous system:

         Patients is conscious. 

         Speech is normal. 

         Reflections are normal. 

Provisional diagnosis:

Viral pneumonia

Investigations:

Hemogram

         Heamoglobin-11. 5

         Total leucocyte count-12500

         PLT-4. 9

Serum Electrolytes:

   

        

    Treatment Given

             On Day 1:

             1.IVF-2 NS @75ML/HR

             2.INJ OPTINEURON 1 AMP IN 100 ML NS IV OD

             3.SYP ASCORIL 10 ML PO BD

             4.TAB AUGMENTIN 625 MG PO BD

             5.TAB PCM 650 MG PO BD

             6.TAB PAN 40 MG PO OD

             7.NEB WITH BUDECORT 12 TH HRLY,DUOLIN 8TH HRLY

             8.MONITOR VITALS 4TH HRLY  

            DAY 2:

            1.IVF-RL, NS @75ML/HR

            2.SYP ASCORIL 10 ML PO BD

            3.TAB AUGMENTIN 625 MG PO BD

            4.TAB PCM 650 MG PO BD

            5.TAB PAN 40 MG PO OD

            6.NEB WITH BUDECORT 12 TH HRLY,DUOLIN 8TH HRLY

            7.TAB AZITHRAL 500 MG PO OD

             8.INFORM SOS

            DAY 3:

            1.IVF-RL, NS @75ML/HR

            2.SYP ASCORIL 10 ML PO BD

            3.TAB AUGMENTIN 625 MG PO BD

            4.TAB PCM 650 MG PO BD

            5.TAB PAN 40 MG PO OD

            6.NEB WITH BUDECORT 12 TH HRLY,DUOLIN 8TH HRLY

            7.TAB AZITHRAL 500 MG PO OD

             8.INFORM SOS

            Advice at Discharge

             1.TAB AUGMENTIN 625 MG PO BD FOR 3 DAYS

             2.TAB PAN 40 MG PO OD FOR 5 DAYS

             3.SYP ASCORIL 10 ML PO BD

             4.TAB PCM 650 MG PO BD FOR 5 DAYS