17 yr old male with cough under evaluation

 Rambai 

Roll no 89 

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is a case of 17 yr old male , student by occupation , resident of Nalgonda came to casualty with chief complaint  of  cough since 10 days .

Patient was apparently asymptomatic 10 days back ,then he developed cough which is insidious in onset, initially not associated with expectoration but from last 2 days associated with mucopurulent sputum , continuous in nature ,no postural,diurnal variations ,non foul smelling ,non blood tinged with no aggravated and relieving factors .cough was also associated with chest tightness .

No h/o fever , breathlessness,chest pain, sweating , palpitations .

H/o vomiting - 1 episode in the morning with food particles as content ,non projectile .

No h/o loss of appetite ,loss of weight 

No H/o allergies in the past 

PAST HISTORY : 

No H/o similar complaints in the past 

No h/o TB in the past 

No h/o inhaler usage in the past  

N/k/c/o DM,HTN ,ASTHMA , EPILEPSY ,CAD

PERSONAL HISTORY: 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder - regular 

No Addictions 

ON EXAMINATION 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing, cyanosis,lymphadenopathy ,edema 

Vitals : 

BP - 110/70mmhg

PR- 82bpm

Spo2 -99% at room air 

GRBS - 87 mg/dl

Temperature- 98.1F   

RR- 20CPM 

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM: 

On inspection :

URT

Nose - DNS + right sided , no polyps

Oral cavity - normal

Posterior pharyngeal wall - normal

LRT 

Chest wall - symmetrical and eliptical

Trails sign - negative

Supraclavicular and infraclavicular halloconess absent

Movement of chest appears to be equal on both sides

No crowding of ribs, wasting of muscles, dropping of shoulder 

Apex beat is not seen

Spino scapular distance is equal on both sides

No scars, sinuses, engorged veins

 ON PALPATION : 

All inspectory findings are confirmed 

Trachea is central in position 

Apex beat - left 5 th ICS just lateral to MCL 

No local rise of temparature 

No tenderness 

TVF - equal on both sides  

PERCUSSION: 

Direct - resonant

Mediated - resonant 

AUSCULTATION: 

B/l air entry present 

Vesicular breath sounds heard 

No added sounds  

VR - equal on both sides  

CVS :

S1,S2 Heard ,no murmurs 

P/A : soft ,non tender 

       Bowel sounds heard 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

Reflexes:

       R       L

 B  ++      ++

 T  ++      ++

S  ++     ++

K  ++     ++

A  ++     ++

P Flexor  Flexor    

DIAGNOSIS: 

ACUTE EXACERBATION OF COUGH 

WITH ?ACUTE BRONCHITIS 

TREATMENT: 

*INJ.AVIL 1 VIAL IM STAT 

* SYP.ASCORIL D 15 ML PO TID 

*NEBULIZATION WITH BUDECORT 12 TH HOURLY DUOLIN 12 TH HOURLY 

*INJ.CEFTRIAXONE 1 GM IV BD 

*T.MONTEC LC HS OD