45 years old female with shortness of breath

Chief complaints : 
Fever since 10 days
Giddiness since 3 days
Dry cough since 3 days
Loose stools since 1 day
Vomiting since 1 day

History of present illness :
Patient was apparently asymptomatic since 10 days and then she developed fever which is associated with the chills and rigor and with diurnal variation increased during night and subsided by night and she had giddiness and shortness of breath since 3 days and then for which she went RMP doctor and he gave ORS and from then she had 1 episode of vomiting non projectile non bilious contains food particles and she had 1 episode of loose stools since 1 day and she has history of dry cough since 3 days .

History of past illness : 
She is not known case of diabetes, hypertension, epilepsy,CVA,CAD, thyroid disorders.



PROVISONAL DIAGNOSIS : 
Acute pulmonary Koch 


S 
Dry cough 
Stool passed + 
No Fever spikes 
Decreased tingling sensation of wrists 
O 
Pt is conscious ,coherent , cooperative
Temp: 
BP: 100/70 mmHg 
PR : 72 bpm 
RR :  24cpm 
SpO2 : 100
GRBS : 120 mg /dl 
CVS : S1 S2 + 
RS : BAE + 
        Trachea central 
        Wheeze + in Infra axillary
         Crepts (fine ) + in Infra axillary and Infra scapular 
CNS :NAD ,HMF+ 
P/A :  Soft and non tender 
 

Hemogram : 
Hb- 8.2 mg/dl 
TLC - 5,900 cells /cumm
PLT - 5.7 lakhs /cumm 


Serum Electrolytes : 
Na +  :  136 mEq/L 
K+  :   3.8 mEq /L 
Cl-  :  101mEq /L 

A 
Acute Pulmonary Kochs( Sputum +ve ) 
Septic shock (resolved ) 
Acute GE (resolved ) 
AKI (Pre renal > renal ) ( resolved ) 


P 

1) T. ATT  3 tabs/ day  PO/OD 
     H - 5mg /kg - 250mg 
     R - 10mg/kg - 500mg 
     Z -  25mg/kg - 1250mg
     E - 15mg /kg -  750mg 
2) Neb with Duolin-4th hrly 
                     Budecort -8th hrly 
3) Inj . Hydrocort 100mg /IV /TID 
4) Inj .Pan 40mg IV/TID 
5) Tab .Benadon 40mg PO/OD 
6) Tab .Ecospirin -AV 75/10 NS  PO/HS 
7) Oint . Thrombophobe L/A / 3 times 
8) BP monitoring  2nd hourly 
9) Temp  Monitoring 4th hourly 
10) Vitals Monitoring 6th hourly

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