A PATIENT WITH FEVER AND COUGH

HISTORY OF PRESENT ILLNESS

GENERAL DATA CHIEF COMPLAINT
4d PTA when she noted the onset of cough, Productive Cough, Yellow
Mrs X, Aged 71 ,Female , retired lawyer Fever And Cough sputum, Fever with chills - 38.9 degrees Celsius, Chest pain,

Y OF
HISTOR

HISTORY OF PAST ILLNESS

PRESEN
Congestive heart failure related to ischemic heart
disease controlled by Lasix, an ACE- inhibitor, and
T PERSONAL AND SOCIAL HISTORY

Former smoker already quit 3 mos ago, Lives alone in the City, Diseased
Lopressor.
ILLNESS husband, due to lung cancer.

HISTOR
Y OF TEMPERATURE 39.4 c

GENERAL SURVEY
PAST VITAL SIGNS
BP 128/84

PR 120/ MIN
O2 saturation:

ILLNESS
Thin and in Mild respiratory distress 89%

RR 28/ MIN

PHYSICAL EXAMINATION
PERSON
Skin: decreased turgor( dehydration and old age), HEENT: tympanic membrane and oropharynx mildly red
but no exude, CHEST: remarkable for splinting to the left side on deep inspiration + dullness to percussion ≈
1/4 way up on left side; decreased breath sounds at left base, but egophony(sign of consolidation) and

AL AND
bronchial breath sounds are evident as one listens more superiorly on the left side. The right chest is clear

All Other Physical Examination Are

SOCIAL
Normal

HISTOR
Y
GENERA
Leukocytosis, Elevated FBS result, Proteinuria (transient), Sputum Gram stain: few PMN, many epithelial cells, and
LAB EXAM scattered, Gram positive and Gram negative cocci and rods are seen

L ,
SURVEY
PRIMARY IMPRESSION
Thin Man
COMMUNITY ACQUIRED PNEUMONIA(BACTERIAL)
Appearing
Older Than
 BASIS: BASIS

• Fever(38.9degreesCelsius) • Oropharynx mildly red

• Productive cough(yellow • Mild Respiratory distress-[Dyspnoea
sputum) (O2sat.-89%)]
• Chills • Tachypnea (RR -28)
• Chest Pain • Tachycardic (PR- 120)
• congestive heart failure related • splinting to the left side on deep
to ischemic heart disease inspiration
• Smoker • Dullness to percussion
• Thin • Consolidation in Superior left side
• Tms mildly red • Egophony
• Bronchial sound
•
DIFFERENTIAL DIAGNOSIS red • Leukocytosis

Rule In
Viral Pneumonia
• Fever Rule out
• Productive cough
• Chills
• Dry cough
• Chest pain
• Mucoid sputum
• History of smoking/smoker
• Malaise
• Tachypnea
• Headache
• Tachycardic
• Dyspnoea

Tuberculosis Rule Out

• Diurnal fever
• Night sweats due to weight loss or
• Anorexia
Rule In • General malaise and weakness
• No haemoptysis
• Fever • No wasting
• Productive cough • Pallor finger clubbing
• Thrombocytopenia
• Mild anaemia

Stable Vital signs RR<30/minute PR<125/min, SBP> 90 mm Hg DBP>60mmHg

Temp >36oC or <40oC . No altered mental state of acute onset No suspected
Low risk CAP aspiration . Stable c o-morbid
conditions
Chest X ray
– localized infiltrates – No evidence of pleural effusion
TREATMENT

Co-amoxiclav 1 gm BID OR Sultamicillin 750 mg BID OR Cefuroxime axetil 500 mg BID +/-
Azithromycin 500 mg OD OR Clarithromycin 500 mg BID

GROUP 13
Vepuri, Sasi Naga Suvarchala
Pathan, amish Ajitkhan
Jha, Priyanka Sunil
Pande, Milap Hemantkumar
Sukrux, Phuwara
Aphiwatthananakorn, Suttipong
Mahadevan Remani, Lekshmi
Britto Santhakumar, Shabin Santhakumar
Balachandran, Ajith
Pajany, Mamtha Rajsre
Dey, Rajat Kumar
Raju, Aravindaraj
Nai, shannikumar Jagbishbhai
Kuhasubpasin, siripatsorn
Baraiya, Rakesh Damjibhai