30YR OLD FEMALE WITH FEVER ,COUGH AND DYSPNEA AS CHIEF COMPLAINT.


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.


CASE : 30yr old female ,labourer by occupation,resident of nakrekal came with chief complaints of 
1. Fever since 14 days
2. Cough since 10 days
3. Shortness of breath since 2 days.

History of present illness :
The patient was apparently asymptomatic 14 days back ,then she developed 

1. Fever which is insidious in onset,low grade fever,with evening rise of temperature associated with chills and rigor,for which she took medication at local hospital in nakrekal.

2. Cough,which is dry,nonproductive ,gradually progressive , episodic (3-4 episodes per day,each lasting for 2-3 min).

3. Shortness of breath grade 2 according to MRMC.

No history of chest pain,hemoptysis,palpitations, paroxysmal nocturnal dyspnea ,pedal edema,burning micturition,vomitings,loose stools.


Past history :
No similar complaints in the past.
Not a known case of HTN, DM,TB,asthma,epilepsy,thyroid disorders.


Family history : 
Insignificant.

Personal history :
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
No addictions.


GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative.
Thin built and moderately nourished.

Pallor present.
No icterus, cyanosis, koilonychia, clubbing, lymphadenopathy, edema.

Vitals :
Temperature - Afebrile
PR - 74 bpm
RR - 38 cpm
BP - 90/60mm Hg

Systemic Examination :
Respiratory system -
Inspection :
Shape of the chest - normal
No visible scars
Usage of accessory muscles present
Position of trachea - central

Palpation :
Trachea central
No local rise of temperature
No tenderness
Chest expansion decreased on right side compared to left side
Vocal fremitus increased on right side infrascapular

Percussion :
Dull note at 4th and 5th ICS on right side

Auscultation :
Vocal resonance increased on right side infrascapular area
Bronchial breath sounds present 
Crepitations on right side infrascapular area


Following is the analysis in my case:

Anatomical location -
Right lower lobe

Pathology-
Consolidation

Etiology-
Probably infective cause


Investigations done : 
CHEST X RAY ,CBP

Chest X ray findings -
Consolidation in right lower lobe seen
CBP -
Mild pallor present 
Probable diagnosis :
Pneumonia in right lower lobe

Treatment : 
Tab dolo 650mg
Pan 40mg
Azithromycin 
3rd generation cephalosporins
Benadryl cough syrup.

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