A 56 YEAR OLD MALE
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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.
A 56 yr old male came to the casualty with C/O
Generalized weakness since 15 days
Fever since 10 days
SOB (GRADE 4 ) Since 5 days
Fever: high grade associated with chills and rigor , intermittent associated with cold,cough (productive - small quantity,mucoid,non - foul smelling, headache present, generalized weakness present
SOB:
SOB of grade 2 to 4 since 5 days
Not associated with orthopnea,PND,pedal edema, palpitations, facial puffiness, decreased urine output
PAST HISTORY
He had scar over right infrascapular area due to trauma with electric pole(30 yrs back)
H/o surgery for renal calculi (10 yrs back)
Not a k/c/o HTN,DM,asthma,epilepsy
PERSONAL HISTORY
Diet-mixed
Appetite- decreased
Bowel and bladder movements- regular
Addictions- he drinks alcohol daily 90 ml since 10 yrs ,smokes biddi since 30 yrs ( per day 1 packet)
On examination
pt is c/c/c
Moderately built , moderately nourished
No pallor,icterus, clubbing, cyanosis, lymphadenopathy
Vitals:
Afebrile
Bp-100/70 mmhg
Pr-96 bpm
RR- 20 cpm
Spo2-90% on RA
Systemic examination:
Cvs-S1,S2 heard
Rs- dyspnea +
Crepts + in all areas
Trachea- central
Breathe sounds- vesicular
No additional sounds
CNS- NAD
PROVISIONAL DIAGNOSIS
? COMMUNITY ACQUIRED PNEUMONIA
?COPD
?VIRAL PNEUMONIA SECONDARY TO COVID-19
INVESTIGATIONS
On 28/8/21
On 30/8/21
On 1/9/21
Pft
TREATMENT:
ON 28/8/21
1.O2 Inhalation to maintain SPO2 >90%
2. Inj.ceftriaxone 1gm/iv/bd
3. Inj.pan 40 MG /iv/of
4. Inj.neomal 100 ml iv/sos if temp >101 F
5. Nebulisation with duolin,budecort,mucomist 6th hrly
6. Tab.pcm 650 mg po/tid
7. Tab.montec LC/po/hs
8. Bp/pr/rr/temp charting 4th hrly
On 29/8/21
1.O2 Inhalation to maintain SPO2 >90%
2. Inj.ceftriaxone 1gm /iv/bd
3. Inj.pan 40 MG /iv/of
4. Inj.neomal 100 ml iv/sos if temp >101 F
5. Nebulisation with duolin,budecort,mucomist 6th hrly
6. Tab.pcm 650 mg po/tid
7. Tab.montec LC/po/hs
8. Bp/pr/rr/temp charting 4th hrly
On 30/8/21
SOAP NOTES
DAY 3
A 56 YEAR OLD MALE
SUBJECTIVE:
Fever
Cough
SOB ( grade 4)
OBJECTIVE:
BP:130/70
PR:80 bpm
SPO2:94 percent
ASSESSMENT
? VIRAL PNEUMONIA
PLAN OF TREATMENT:
1.O2 Inhalation to maintain SPO2 >90%
2. Inj.ceftriaxone 1gm /iv/bd
3. Inj.pan 40 MG /iv/of
4. Inj.neomal 100 ml iv/sos if temp >101 F
5. Nebulisation with duolin,budecort,mucomist 6th hrly
6. Tab.pcm 650 mg po/tid
7. Tab.montec LC/po/hs
8. Bp/pr/rr/temp charting 4th hrly
9.Tab pulmoclear bd
SOAP NOTES
DAY 3
A 56 YEAR OLD MALE
SUBJECTIVE:
Fever
Cough
Generalized weakness
OBJECTIVE:
BP:100/60
PR:74 bpm
SPO2:97 percent
ASSESSMENT
? VIRAL PNEUMONIA
PLAN OF TREATMENT:
1.O2 Inhalation to maintain SPO2 >90%
2. Inj.ceftriaxone 1gm /iv/bd
3. Inj.pan 40 MG /iv/of
4. Inj.neomal 100 ml iv/sos if temp >101 F
5. Nebulisation with duolin,budecort,mucomist 6th hrly
6. Tab.pcm 650 mg po/tid
7. Tab.montec LC/po/hs
8. Bp/pr/rr/temp charting 4th hrly
9.Tab pulmoclear bd
SOAP NOTES
DAY 5
A 56 YEAR OLD MALE
SUBJECTIVE:
Cough
Generalized weakness
OBJECTIVE:
BP:100/60
PR:76bpm
SPO2:97 percent
ASSESSMENT
?COPD
? VIRAL PNEUMONIA
PLAN OF TREATMENT:
1. Inj.ceftriaxone 1gm /iv/bd
2. Inj.pan 40 MG /iv/of
3. Inj.neomal 100 ml iv/sos if temp >101 F
4. Nebulisation with duolin,budecort,mucomist 6th hrly
5. Tab.pcm 650 mg po/tid
6. Tab.montec LC/po/hs
7. Bp/pr/rr/temp charting 4th hrly
8. Tab.pulmoclear 600 mg/po/bd
9. Tab.ultracet 1/2 tab qid
10. TAB.MVT po/od
11. Tab .pregabalin 75 mg po/hs
12.syrup.Grillnicus 15 ml/ po/tid
SOAP NOTES
DAY 6
A 56 YEAR OLD MALE
SUBJECTIVE:
Cough
Generalized weakness
OBJECTIVE:
BP:100/70
PR:80bpm
SPO2:98 percent
ASSESSMENT
?COPD
? VIRAL PNEUMONIA
PLAN OF TREATMENT:
1. Inj.ceftriaxone 1gm /iv/bd
2. Inj.neomal 100 ml iv/sos if temp >101 F
3. Nebulisation with duolin,budecort,mucomist 6th hrly
4. Tab.pcm 650 mg po/tid
5. Bp/pr/rr/temp charting 4th hrly
6. Tab.pulmoclear 600 mg/po/bd
7. Tab.ultracet 1/2 tab qid
8. TAB.MVT po/od
9. Tab .pregabalin 75 mg po/hs
10.syrup.Grillnicus 15 ml/ po/tid
SOAP NOTES
DAY 7
A 56 YEAR OLD MALE
SUBJECTIVE:
Generalized weakness
OBJECTIVE:
BP:120/80
PR:90bpm
ASSESSMENT
?Acute excerabations of COPD
PLAN OF TREATMENT:
1. Inj.neomal 100 ml iv/sos if temp >101 F
2. Nebulisation with duolin,budecort,mucomist 6th hrly
3. Tab.pcm 650 mg po/tid
4. Bp/pr/rr/temp charting 4th hrly
5. Tab.pulmoclear 600 mg/po/bd
6. Tab.ultracet 1/2 tab qid
7. TAB.MVT po/od
8. Tab .pregabalin 75 mg po/hs
9.syrup.Grillnicus 15 ml/ po/tid
