54 yr old male with Left upper lobe pneumonia secondary to Koch's

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.

Team:

Interns-

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha


Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)

54yr old male  present with 
C/o chest pain since 10 days 
C/o SOB since 10 days 
C/o cough with expectoration since 10 days

pt was apparently asymptomatic 10days back then developed chest pain on Left side which is pricking type ,sudden in onset ,non radiating aggravated on exertion a/w SOB  which is grade 3 and cough with expectoration which is in yellow in color,non blood stained,non foul smelling
c/o fever since 10days a/w chills and rigors, body aches which is high grade, intermittent relieved on medication 
H/o weight lose and evening rise of temperature since 15 to 20 days
No H/o palpitations, PND, burning micturition, loose stools, decreased urine output
-Past history-
No H/o DM, HTN, CVA,ASTHMA, Epilepsy, TB
O/E
pt is conscious coherent cooperative
No signs of pallor, icterus, cynosis, clubbing, lymphedenopathy, koilonychia,Generalized edema 
vitals
temp-afebril
pulse-82bpm
BP-130/80mmHg
Resp rate-16 cpm
spo2-97%
Systemic Examination 
CVS-s1,s2 +
R/S
-inspection-
trachea appears to be centeral
shape-eliptical 
Respirator parttern - Thoraco abdominal 
chest Movements- moving equally on respiration
no scars,no sinus ,supra clavicular hallowness absent ,no use of accessory muscle
-palpation-
Trachea central
no local raise of temperature, no Tenderness 
All inspectory findings confirmed 
chest expansion 4cm
vocal fremitus decreased on left suprascapular region
-percussion-
resonanat on both side on percussion 
-Auscultation-
Reduced breath sound in left suprescapular area
No added sounds
P/A 
soft non tender 
CNS-NAD

Investigations



Treatment 
ON THE DAY OF ADMISSION 
1.INJ AUGMENTIN 1.2GM/IV/BD
2.INJ PANTOP 40MG/IV/BD
3.TAB AZITHROMYCINE 500MG/PO/OD
4.NEBULIZATION DUOLIN-6TH HOURLY,BUDECORT 8TH HOURLY
5.syp.citralka 10ml in 1 glass of water/po/BD
6.TAB PCM 650MG/PO/SOS
-DAY 1-
1.INJ AUGMENTIN 1.2GM/IV/BD
2.INJ PANTOP 40MG/IV/BD
3.TAB AZITHROMYCINE 500MG/PO/OD
4.NEBULIZATION DUOLIN-6TH HOURLY,BUDECORT 8TH HOURLY
5.syp.citralka 10ml in 1 glass of water/po/BD
6.TAB PCM 650MG/PO/SOS
7.INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD
-DAY 2-
1.INJ AUGMENTIN 1.2GM/IV/BD
2.INJ PANTOP 40MG/IV/BD
3.TAB AZITHROMYCINE 500MG/PO/OD
4.NEBULIZATION DUOLIN-6TH HOURLY,BUDECORT 8TH HOURLY
5.syp.citralka 10ml in 1 glass of water/po/BD
6.TAB PCM 650MG/PO/SOS
7.INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD
-PORVISIONAL DIAGNOSIS
?pneumonia secondary to pulmonary tuberculosis

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