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

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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