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Pt Name: Rekha Devi Sharma Age: 52 years

Add: Hathras Mob: +91 81919 90469

Date : 07/06/2023

Rx

Patient Name: Rekha Devi Sharma

Admission Date: 5th June 2023

Discharge Date: 6th June 2023

Chief Complaint: The patient, Rekha Devi Sharma, presented with complaints of respiratory
distress, cough, and fever.

Medical History: Rekha Devi Sharma hasv a medical history of mild asthma, but she has not
experienced any recent exacerbations. She has no known allergies to medications or
environmental factors. She is a non-smoker and denies any significant exposure to second-
hand smoke or occupational hazards.

Presenting Illness: Rekha Devi Sharma was admitted to the hospital on 5th June 2023 with
complaints of progressively worsening respiratory symptoms. She reported a productive
cough with yellowish sputum, shortness of breath, and intermittent low-grade fever for the
past four days. Her symptoms were associated with fatigue and generalized weakness. There
was no history of chest pain, haemoptysis, or orthopnoea.

Physical Examination: On examination, Rekha Devi Sharma appeared ill and was in respiratory
distress. Her vital signs were as follows:

 Temperature: 38.5°C

 Blood pressure: 120/80 mmHg

 Heart rate: 95 bpm

 Respiratory rate: 28 breaths per minute

 Oxygen saturation: 92% on room air

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Pulmonary auscultation revealed bilateral coarse crackles and decreased breath sounds in the
lower lung fields. The rest of the physical examination was unremarkable.

Diagnostic Workup: To evaluate the patient's respiratory symptoms, several investigations

were conducted:

1. Chest X-ray: The chest X-ray revealed patchy opacities in bilateral lung fields,
consistent with a diagnosis of lung infection.

2. Complete blood count (CBC): The CBC showed an elevated white blood cell count
with a left shift, indicating an acute infection.

3. Sputum culture and sensitivity: A sputum sample was collected and sent for culture
v the causative organism and guide appropriate
and sensitivity testing to identify
antibiotic therapy.

Diagnosis: Based on the patient's clinical presentation and diagnostic workup, Rekha Devi
Sharma was diagnosed with a lung infection, most likely of bacterial origin.

Treatment: Rekha Devi Sharma was initiated on intravenous antibiotics, including a broad-
spectrum cephalosporin, to target the suspected bacterial infection. Oxygen supplementation
was provided via nasal cannula to maintain adequate oxygen saturation. Supportive
measures, including hydration and rest, were also provided to facilitate recovery.

Progress and Follow-up: During her hospital stay, Rekha Devi Sharma showed gradual
improvement in her symptoms. Her fever subsided, and her respiratory distress reduced.
Repeat chest X-ray demonstrated partial resolution of the previously noted lung opacities.

On the 6th of June 2023, Rekha Devi Sharma's condition had significantly improved, and she
no longer required supplemental oxygen. Her vital signs were stable, and her physical
examination revealed decreased crackles on pulmonary auscultation.

Therefore, Rekha Devi Sharma was discharged with a prescription for a course of oral
antibiotics to complete her treatment. She was advised to follow up with her primary care
physician for further evaluation and monitoring.

Summary: Rekha Devi Sharma, a female patient with a history of mild asthma, was admitted
to the hospital with symptoms of a lung infection. The diagnosis was confirmed based on
सरस्वती वीणा मल्टीस्पेशलिटी अस्पताल
clinical examination, chest X-ray findings, and laboratory investigations. She responded well
to intravenous antibiotics and supportive care during her short hospital stay. Discharged on
the 6th of June 2023, she was prescribed oral antibiotics for further treatment and advised to
follow up with her primary care physician for further evaluation and monitoring.

Dr Rahul Tivari