30 year old female with c/o cough since 10 days and sob since 2 days































 DR. YAMINI ( INTERN)

DR. AMULYA ( INTERN) 

DR. SURYA PRADEEP ( INTERN)

DR. ASHA KIRAN ( INTERN)
DR. JAYANTH ( INTERN) 
DR. VAMSHI ( INTERN)
DR. ISMAIL ( INTERN ) 
DR. PRADEEP ( PG 1st YEAR)
DR. DIVYA (PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI

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. Here is a case i have seen: 
A 30 year old female who is a house wife came to casualty at 11.00 pm with c/o fever since 10 days cough since 10 days and shortness of breath since 2 days. 
Patient was apparently asymptomatic 10 days back later she developed fever which was insidious in onset low grade with evening rise of temperature not relieved on medication associated with chills and rigors 
Fever is associated with dry cough since 10 days not associated with any postural or diurnal variation, cough is associated with pain in right side of chest. Cough was progressive associated with shortness of breath since 2 days more in the evening 
No PND, orthopnea, 
Not a k/c/o HTN, DM, asthma, epilepsy, CVA, CAD 
No h/o pedal edema, chest pain, palpitations, headache, tinnitus, blurring of vision 
On examination: 
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 
No signs of malnutrition or dehydration 
Vitals: 
Temp: 98.4OF 
PR: 92/ min 
RR- 28/min 
BP- 90/60 mmhg 
SpO2- 98% on RA 
GRBS- 156 mg/dl 




CVS- S1 S2 heard 
RS- dyspnea present 
Decreased bilateral air entry 
Decreased breath sounds on right side fine inspiratory crepitations 
Bronchial breath sounds on right IAA, IMA, ISA 
P/A- soft non tender 
Bowel sounds heard 
CNS- patient is conscious, coherent and cooperative 
Speech- normal 
No signs of meningeal irritation 
Cranial nerves intact 
Reflexes intact 
No cerebellar signs 

Investigations: 






Provisional diagnosis : 
Right upper lobe posterior segment consolidation 
Rt lower lobe consolidation 
Bilateral patchy consolidations 
? Pneumonia 
Treatment: 
  1. IVF 1 unit NS 1 unit RL @75ml/ hour 
  2. Inj. Augmentin 1.2gm/IV/BD 
  3. Tab. Azithromycin 500mg/ PO/ BD 
  4. Inj. Pan 40mg/ IV/ OD 
  5. Inj. ZOFER 4mg/ IV/ SOS 
  6. Inj. Optineuron 1 amp in 100ml NS / IV/ BD 

Outside reports: 
Sputum for cbnaat - negative done on 27-02-2021 


Discussion : 

Anatomical localisation of the problem is in the lungs 

Infective etiology 

Planning for RT-PCR to rule out covid-19 

Day-1 ( 03-03-2021) 

S- fever spikes + at 100oF 
Passed stools 
O- pt is c/c/c 
Temp- 100OF 
PR- 110/ min 
BP- 100/70 mmhg 
RR- 40/min 
GRBS- 122mg/dl 
SpO2- 94% on RA 
CVS- S1S2 + 
RS- BAE + 
Decreased breath sounds on right side 
Fine inspiratiry crepts 
Bronchial breath sounds on right IAA, IMA, ISA 
P/A- soft, BS+ 
CNS- no focal deficits 
A- 1. community acquired pneumonia 
    2. Anemia    ? 1st degree Heart block 
P- 
Rx- 
  1.  IVF 1 unit NS and 1 unit RL @50ml/hour 
  2. Inj. PAN 40mg/IV/OD 
  3. Inj.AUGMENTIN 1.2g/IV/BD 
  4. Tab. AZITHROMYCIN 500mg/ PO/OD 
  5. Inj. Optineuron 1 amp in 100ml NS/ IV/OD 
  6. BP, PR, RR, SpO2 monitoring 
  7. Tab. DOLO 650mg / PO/ TID
  8. Tepid sponging SOS
  9. Strict I/ O charting 
  10. Temp. Charting 4th hourly 
  11. Nebulisation with ipravent 8th hourly 12th hourly 
  12. Syp. Benadryl 10ml/PO/ BD

Day-2 ( 04-03-2021) 
S- Shortness of breath decreased subjectively, cough decreased, fever spikes present 
O- Pt is c/c 
Temp- 100oF 
BP- 90/50mmhg 
PR- 84/min 
RR- 38/min
GRBS- 119mg/dl at 8.00AM 
CVS- S1 S2 + 
RS- B/L AE+, decreased breath sounds on right side, bronchial breath sounds in right infrascapular area 
CNS- no focal deficits 
P/A- soft nontender 
A- 1. Community acquired pneumonia 
  1.  anemia ? 1o degree heart block
P- 
Rx- 
  1.  IVF 1 unit NS and 1 unit RL @50ml/hour 
  2. Inj. PAN 40mg/IV/OD 
  3. Inj.AUGMENTIN 1.2g/IV/BD 
  4. Tab. AZITHROMYCIN 500mg/ PO/OD 
  5. Inj. Optineuron 1 amp in 100ml NS/ IV/OD 
  6. BP, PR, RR, SpO2 monitoring 
  7. Tab. DOLO 650mg / PO/ TID
  8. Tepid sponging SOS
  9. Strict I/ O charting 
  10. Temp. Charting 4th hourly 
  11. Nebulisation with ipravent 8th hourly 12th hourly 
  12. Syp. Benadryl 10ml/PO/ BD


Day- 3 ( 05-03-2021) 

S- Shortness of breath decreased subjectively, cough decreased, fever spikes present 
O- Pt is c/c 
Temp- 98.6OF
BP- 90/60mmhg  
PR- 84/min 
RR- 26/min
CVS- S1 S2 + 
RS- B/L AE+, decreased breath sounds on right side, bronchial breath sounds in right infrascapular area 
CNS- no focal deficits 
P/A- soft nontender 
A- 1. Right lobe posterior consolidation 
Right lower lobe consolidation 
Bilateral patchy consolidation 
  1.  anemia ? 1o degree heart block
P- 
Rx- 
  1.  IVF 1 unit NS and 1 unit RL @50ml/hour 
  2. Inj. PAN 40mg/IV/OD 
  3. Inj.AUGMENTIN 1.2g/IV/BD 
  4. Tab. AZITHROMYCIN 500mg/ PO/OD 
  5. Inj. Optineuron 1 amp in 100ml NS/ IV/OD 
  6. BP, PR, RR, SpO2 monitoring 
  7. Tab. DOLO 650mg / PO/ TID
  8. Tepid sponging SOS
  9. Strict I/ O charting 
  10. Temp. Charting 4th hourly 
  11. Nebulisation with ipravent 8th hourly 12th hourly 
  12. Syp. Benadryl 10ml/PO/ BD


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