LOWER RESPIRATORY TRACT INFECTION

22-10-22

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 54 years male patient came to OPD with chief complaint of cold and cough with sputum since 7days. And noticing evening rise of body temperature.

HOPI :

It is apparently asymptomatic until 10 days ago , then he developed

- cough associated with expectoration 

mucoid quantity- 1 cupfilled per day 

-no haemoptysis

-not foul smelling 

* SOB G-1 to G-2 MMRC , normal progressive 

orthopenia , PND 

* Fever - low grade, continuous evening rise of temperature 

- no H/O chest pain / pedal edema

- no H/O abdominal pain / constipation/ hemetemesis 

-no H/O chest trauma

PAST HISTORY: 

k/c/o HTN 

No similar complaints in the past 

n/k/c/o  T2DM /CAD /Thyroid/Epilepsy

k/c/o Ischemic CVA since one yr ( on medication)

FAMILY HISTORY: 

Not significant

PERSONAL HISTORY:

Appetite: normal ( mixed diet )

Bowel and bladder movements: normal

Sleep adequate

Alcohol and smoking: since 40 years - now stopped

General examination : patient was conscious, coherent, cooperative.

VITALS: 

PR : 90 bpm regular

BP : 120/80 mm/b 

Sp O2 : 96 %CRA

CVS : S1 S2 +

RS : B/L air entry + , Inspiration crepts + , L+ MA , , , L+ IMA 

ON PALPATION : soft non tender 

CNS no findings.

INVESTIGATION:

URINE ANALYSIS: 

Color : pale yellow

Quantity: 10 ml 

Appearance: clear 

BLOOD UREA: 32 mg %

CREATININE: 1.3 mg %

DIAGNOSIS: 

LRTI R/O pulmonary kochs with systemic HTN ,

right lower lobe consolidation 

Acute exacerbation of COPD. 

MEDICATION: 

after little progress