REG NO 132820210 Left Lower Lobe Pneumonia 1

REG NO: 132820210

“Left Lower Lobe Pneumonia”

1. PATIENT DETAILS: - NAME : Ms. Y - Age : 17 yrs - Sex : F - I. P No: 197121 - Department : GM - Weight: 58 kg - Height: 165 cm - BMI: 21. 303 - DOA : 19/10/2016 - DOD: 27/10/2016

2. REASON FOR ADMISSION: Patient had c/o: i. Cough for 2 weeks ii. Pleuritic chest pain for 2 weeks iii. Headache(occurred 2 weeks back, and lasted for 5 hours) 3. PAST MEDICAL HISTORY: Not significant 4. FAMILY HISTORY : Not significant 5. SOCIAL HABITS: - Non-smoker - Non- alcoholic

6. KNOWN ALLERGIES : Nil 7. FOOD HABITS: Non-vegetarian

1. VITALS CHART : DATE 19/10 TEMP. 100 B. P 20/10 21/10 22/10 23/10 24/10 25/10 26/10 27/10 99 N N N 120/70 130/80 110/70 130/90 120/70 130/90 120/90 110/90 PULSE 88 RBS 115 RR 22 90 106 80 84 88 86 90 92 20 20 20 24 22 20 24 24

2. BLOOD COUNTS: i. Hb : 12 g/dl ii. ESR: 15 mm/hr iii. Platelet count: 2. 47 lakhs iv. WBC : 10, 140 cells/cumm v. DLC: a. Neutrophils: 80. 5% b. Lymphocytes: 13. 5% c. Monocytes : 5. 2 % d. Eosinophils: 0. 5% e. Basophils: 0. 2%

3. LFTs: i. Total bilirubin: 0. 30 mg% ii. Direct bilirubin: 0. 01 mg% iii. Albumin: 3. 72 mg/dl iv. ALP: 48 IU/L v. SGPT: 10 IU/L vi. SGOT: 18 IU/L vii. Total protein: 6. 74 mg% viii. Globulin: 3. 02 mg%

4. RFTs: i. Urea: 17. 03 mg% ii. Uric acid: 4. 28 mg/dl iii. SCr: 1. 03 mg% 5. ELECTROLYTES: (In m. Eq/L) i. Sodium: 135 ii. Potassium : 4. 0 iii. Calcium: 9. 6 6. OTHERS: - Coarse creps in infrascapular & interscapular area - CNS: WNL - GIT: Soft, non-tender. . .

DIAGNOSIS: “Left lower lobe pneumonia” 2. ASSESSMENT, IF THERAPY INDICATED: 1. i. To alleviate signs and symptoms ii. To avoid complications iii. To reduce ADRs , associated with therapy iv. To improve HRQo. L. . .

3. ASSESSMENT OF CURRENT THERAPY: Drugs given to the patient, involve: i. INJ. MONOCEF(CEFTRIAXONE) ; 1 g i. v; Q 12 H (D 1 & D 4): - 3 rd generation cephalosporin, bactericidal in nature, by working against cell wall synthesis - Covers major spectrums of GRAM NEGATIVE ORGANISMS ii. T. ZITROBACT(AZITHROMYCIN), 500 mg P/O, OD, (D 1 -D 4): - INTIAL DRUG OF CHOICE, as it covers MOST OF PNEUMONIA ETIOLOGICAL AGENTS, INCLUDING MYCOPLASMA SPECIES - Has LESSER ADRs, compared to other drugs used under this disease

iii. T. PAN (PANTOPRAZOLE) ; 40 mg, P/O, OD, (D 1 -D 9): - Proton-pump inhibitor - Has been used to act on GI parietal cells to prevent damages to GI epithelium due to excess acid production, as a tantamount of antibiotics used in the patient. iv. T. DOLO (ACETAMINOPHEN); 650 mg; P/O; (D 1 -D 5): - Helps to reduce fever, and also to alleviate pain(justifiable by the patient having slightly raised temperature in initial days of admission, along with chest pain and headache). v. INJ. TAZOMAC (PIPERACILLIN+ TAZOBACTAM) , 4. 5 g , i. v, Q 8 H (D 4 -D 9): - Effective, since it is ANTI-PSEUDOMONAL , coupled with BETA-LACTAMASE INHIBITOR

vi. CAP. DIPEP(PEPSIN + CELLULASE + FUNGAL DIASTASE+ PAPAIN) , 10 mg, 1 capsule per day, (D 5 -D 9): - Has many implications, but here its used to improve digestion, and enhance affinity towards having good meals. vii. T. MOXIF( MOXIFLOXACIN) , 400 mg P/O, BD(D 3 -D 9): - Fluoroquinolone antibiotic(4 th generation) bactericidal, that disrupts bacterial DNA replication

DRUG NAME DOSE 19/10 Inj. Monocef 1 g i. v Q 12 H Y T. 500 mg P/O , OD Y Y T. Pan 40 mg P/O Y Y Y T. Dolo 650 mg Y P/O, TID Y Y Inj. Tazo mac 4. 5 g i. v Q 8 H Zitrobact 20/10 21/10 22/10 23/10 24/10 25/10 26/10 27/10 Y Y Y Y Y Y Y C. Dipep 1 cap OD T. Moxif 400 mg, P/O , BD Y Y

PROGRESS CHART: 1. 19/10/16: - Patient was febrile - Chest showed coarse creps on left interscapular & infrascapular areas 2. 20/10/16: - Temperature slightly reduced - Patient had c/o consistent cough 3. 21/10/16: - No fresh complaints - Febrile 4. 22/10/16: - No fresh complaints

5. 23/10/16: - No fresh complaints 6. 24/10/16: - Febrile - No fresh complaints - C/0 indigestion 7. 25/10/16: - No fresh complaints 8. 26/10/16: - No fresh complaints 9. 27/10/16: - No fresh complaints, the patient felt better, and was discharged appropriately. . .

DISCHARGE SUMMARY: “ A 17 year old girl, with no other co-morbidities, presented with COUGH, PLEURITIC CHEST PAIN(for 2 weeks), and HIGH GRADE FEVER (for 2 days). On observation: Conscious, oriented, patient was febrile, creps(+ve), X-ray chest done. Patient was treated with i. v antibiotics. Patient was found to improve symptomatically. CT-thorax was planned. Patient was found to be better, and was discharged appropriately. ”

DISEASE-RELATED COUNSELLING: a. Focus on the following remedies: 1. Cayenne pepper 2. Turmeric 3. Black pepper 4. Garlic 5. Ginger 6. Sesame seeds 7. Fenugreek seeds. . .

POINTS TO BE MONITORED: 1. PIPERACILLIN + TAZOBACTAM : - Monitor for LFTs, (AST & ALT levels) - Perform urinalysis and BUN and creatinine levels measurements during therapy 2. MOXIFLOXACIN : - Use, with CAUTION, for PROLONGED THERAPY, since they are associated with SUPERINFECTIONS with prolonged/ repeated therapy - May also cause TENDONITIS/ MUSCLE RUPTURES. . .

THANK YOU !!!!