Threauptics - Case Presentation of Cough and Fever

Threauptics 1 Case presentation BY

PATIENT SENARIO Name : gourappa Age : 45 male Chief complaints Cough with expectorations since 4 days Fever since 4 days

HISTORY OF PRESENT ILLNESS Patient was apparently normal develop Cough with expectorations since 4 days and Fever since 4 days. The symptoms were sudden onset, progressive associated with mucopeurulent pectoration which was blood stained not associated with and chest pain. Fever not associated with chills and rigours.

PAST MEDICAL HISTORY Type 2 DM since 6 years on regular treatment Past medication history : Metformin 500 mg

SOAP Subjective : here is the patient subjected with Cough with expectorations since 4 days and Fever since 4 days

OBJECTIVE Test Test values values Normal range Normal range result result 4000 11000 cu mm W.B.C 18,700 increased esinophils 04 1-3 increased Hb 8.6 12- 14 gm % decreased PCV 33.6 35-46 % decreased MCH 21.2 32-36 pg decreased MCHC 25,6 32-36% decreased Platelet count 6.52 1-3 lakhs increased ESR 90 < 20 mm increased Hb.A1c 7.8 % increased

Chest x ray : Right upper lobe consolidation Sputum : Organism isolated is streptococcus pneumonia sensitive to pipericillin and tazobactam sputum AFB : negative

Increase in W.B.C count is due to severe deliberating illness , immunodeficiency Increase in eosinophils is due to allergic reactions like asthma , fever and due to parasitic infections. Decrease in PCV,MCH,MCHC is due to anemia Increase in ESR is due to acute or chronic infections

ASSESSMENT Problem 1 : cough It occurs due to the presence of any exogenous substances and a endogenous stimuli where it expels the obstruction causing substances from respiratory tract Problem 2 : fever Its occurs due to the presence of pyrogens which are the toxic substances released from the disease causing organisms.

Problem 3 : type 2 DM It occurs due to the insulin ressistanace to the tissue and poor intake of glucose by skeletal muscles. Problem 4 :pneumonia Its a inflammatory condition of the lung affecting the microscopic air sacs of lungs known as alveoli, mostly caused by bacteria and virus.

THREAUPTIC PLAN Brand name Brand name Generic name Generic name dose dose Dates of treatment Dates of treatment 12/3 13/3 14/3 15/3 12/3 13/3 14/3 15/3 16/3 16/3 T.Calpol 1-1-1 Paracetamol 650mg Y Y Y Bromohexine 1-1-1 bromohexine 3 tea spoons Y Y Y Y Y T.fortamet 1-0-1 metformin 500mg Y Y Y Y Y T.Piptaz 1-0-1 Piperacillin + tazobactam 1.5gm Y Y Y Inj.acigon 1-0-0 pantaprazole 20 mg Y Y Y Y Y Syp.replyex fort 1-0-1 Vitamin b complex 2 tea spoons Y Y Y Y

Problem 1 : cough Bromohexine 3 teaspoons daily It acts as a secretolytic agent which increase the production of serous mucus in the respiratory tract and makes phelgem thinner and less viscous, thus it clears the mucus from respiratory tract. Problem 2 : fever T.Calpol [paracetandmol] 650mg It reduces fever by inhibiting the formation and release of prostaglandin in CNS and by inhibiting endogenous pyrogens at hypothalamic thermoregulatory center.

Problem 3 : type 2 DM T.Fortamet[metformin 500mg BD ] It acts by decreasing the hepatic glucose production and peripheral insulin sensitivity. Problem 4 : pneumonia T.Piptaz [piperacillin + tazobactam ] Piperacillin acts by inhibiting the peptidoglycan synthesis which is a important component of cell wall. Tazobactam acts by inhibiting the beta lactamase .

Others Inj,acigon : [pantaprazole] pump inhibitor It acts by supressing the final step in gasteric acid production and leads to inhibition of both basal and stimulated acid secreations. Syp.rayplex fort Vitamin suppliment.