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40 Y/M with fever , 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have 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 diagnosis and treatment plan   


13-08-2022


40 Y/M who is farmer and a resident of Nalgonda has come to OPD with chief complaints of

*Fever and cough since 3 days

*SOB since 1 day


History of present illness

The patient was apparently asymptomatic 3 days ago then he got drenched in rain and developed fever that was insidious in onset , continuous and associated with chills and rigor, cold and dry cough

The patient developed shortness of breath on rest and was rushed to hospital

No h/o headache, nausea , vomitings , chest pain, post nasal drip .

Past history

Patient developed pedal edema and decreased urine output 2 months ago, that subsided on medication.

Personal history

He is married

Diet - mixed

Appetite - Decreased since 3 day

Sleep - Inadequate

Bowel and bladder -Regular

Addiction - Consumes alcohol everyday (approx 90ml)

Allergies - None


Family history 

Not significant


GENERAL EXAMINATION

Thin built and malnourished 

Vitals

Temperature : Afebrile 

Pulse: 90

BP:120/70 mm/ hg

RR :26

SPO2 : 92%

GRBS:127 MG%


Pallor : ABSENT 

Icterus : ABSENT 

Clubbing :ABSENT

Cyanosis :absent

Lymphadenopathy: absent

Pedal edema: absent




SYSTEMIC EXAMINATION

CVS
 S1 S2 heard , no murmers 

RS

Bilateral air way entry is present
Wheeze - present ( bilateral)
Crepitations - present ( bilateral)
Dull note on Percussion is seen.
( Right - Anterior
Left - Anterior, Posterior)

CNS- NFND

P/A-soft, non tenderness

Provisional diagnosis

ARDS?
Pneumonia?

Plan:
Inj piptaz 4.5gm Iv TID
Tab Doxy 100mg PO BD
Other Supportive care


Investigations 








Day 1






Day 2

Patient is conscious, coherent and cooperative

Bp-110/80 mm Hg 
PR- 65bpm

RR- 22cpm

TEMP -98°F

GRBS-149mg/dl

CVS-S1,S2+

R/S-BAE+,right sided coarse

crepts- ISA,ICA,IAA, left sided IAA crepts+

P/A-soft,nontender CNS-NFND

Provisional diagnosis 

ACUTE RESPIRATORY DISTRESS SYNDROME SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA SECONDARY TO VIRAL ETIOLOGY? ATYPICAL PNEUMONIA WITH DENGUE IgM+

Treatment 

1)IVF-NS @50 ML/HR IV INFUSION
2) TAB.DOXYCYCLINE 100MG/PO/BD (D2)
 3)TAB.TAMIFLU 75MG/PO/BD 
4)TAB.DOLK 650 MG/PO/QID 
5)INJ.NEOMOL 1GM/IV/SOS(ONLY IF TEMP >101°F WATER/PO/TID
6)SYP.POTCLOR 15 ML IN GLASS OF
7)NEBULIZATION WITH DUOLIN,
BUDECORT-8TH HOURLY
 8)INJ.HYDROCORT 100 MG/IV/TID
 9)SYP.CREMAFFIN PLUS 15 ML/PO/





Day 3

Patient is conscious, coherent and cooperative

Bp-120/80 mm Hg

PR-105bpm

RR- 30cpm

TEMP-99.0°F

GRBS-139mg/dl

CVS-S1,S2+

R/S-BAE+,right sided coarse

crepts- ISA,ICA,IAA, left sided IAA crepts+ 

P/A-soft,nontender CNS-NFND

A

ACUTE RESPIRATORY DISTRESS SYNDROME SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA SECONDARY TO VIRAL ETIOLOGY? ATYPICAL PNEUMONIA WITH DENGUE IgM+

P

1)IVF-NS @50 ML/HR IV INFUSION (D2)- 2)TAB.DOXYCYCLINE 100MG/PO/BD (D2)- 3) TAB.TAMIFLU 75MG/PO/BD 4) TAB.DOLK 650 MG/PO/QID 5)INJ.NEOMOL 1GM/IV/SOS(ONLY IF TEMP >101°F WATER/PO/TID

6)SYP.POTCLOR 15 ML IN GLASS OF

7)NEBULIZATION WITH DUOLIN, BUDECORT-8TH HOURLY

D2-8)INJ.HYDROCORT 100 MG/IV/TID





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