2. Patient ID: 35726/16
Patient name: XYZ
Age: 5 years
Gender: Male
Date of admission: 17/10/16
Date of discharge: 3/11/16
Patient details
3. Patient Complaints
Fever and Chest pain since 30 days.
Breathlessness
Fever was gradual on onset , not associated with chills
Physical Examination-
General condition -- sick
CNS -- Conscious, well
oriented
CVS – S1 and S2 sounds
heard.
Abdomen -- Non-tender, Non-
distended (Normal).
Vital signs-
B.P- 118/80 mmHg
P.R- 80/Min
Resp.- 16/min
Temp.- 99.4 F
Spo2 --- 92%
4. PAST MEDICAL HISTORY :- ICD Insertion
Past Medication History :- Nil
Family History :- Nil
Past History
ICD insertion– An Implantable Cardiovascular
defibrillator (ICD) insertion of an electronic device just below
the collar bone is used to help regulate potentially life
threatening heart rhythms .
5. HAEMATOLOGI
CAL DATA
Investigations Value Normal range
Haemoglobin(Hb) 7.7 (L) 10-14g/dl
Monocytes 16% (H) 2-10%
ESR 120 (H) < 15mm/hr
MCH 23.1 (L) 24-30 pg
MCHC 30.3 (L) 31- 37 g/dl
RBC 2.24 (L) 3.1-5.3millions/cmm
TLC 27500 (H) 4000-11000/cmm
Scr. 0.3 (L) 0.8- 1.5 mg/dl
6. USG :
Organized debris in right pleural cavity & few thick septa, which
suggests of emphysema.
Collapse /consolidation of right lung.
Culture Report:
Technique- Zeil-Neelson Staining
Result- No acid fast bacilli seen.
Gram staining – No microorganism seen.
Other Investigations
7. On the basis of Laboratory investigations and
Radio imaging, the patient was diagnosed as
Emphysema.
Final Diagnosis
8. Surgery
Surgery was done to remove damaged
area of the lung and also Pleural fluid was
drained out.
9. MEDICATION CHART
Name, strength, route, frequency Date started Date stopped
Inj.Teicoplanin 140 mg ( iv) 17/10/16 20/10/16
Inj.Tazomac (Tazobactum+Piperacillin)
1.4gm(iv) TDS
20/10/16 Till discharge
Inj.Metrogyl (Metronidazole) 100mg (iv)
TDS
17/10/16 29/11/16
Syp. Zincovit( multivitamin and
minerals) BD
17/10/16 TILL discharge
Syp. Combiflame(
Ibuprofen+paracetamol)
325+400mg/5ml
SOS
20/10/16
Syp. Broncorex
(Bromohexine+terbutaline+Guaifenesin)
2 tsp. BD
29/10/16 TILL discharge
Susp. Lizomac Ds (Linezolid 30ml) TDS 2/11/16
10. DISCHARGE
SUMMARY
Susp. Linezolid 7.5ml TDS X 10 DAYS
Syp. Zincovit 5ml BD
Steam inhalation 3-5 times/day
Syp. Broncorex 2 tsf
Review after 7 days
11. CLINICAL JUSTIFICATION
The treatment given was satisfactory almost as the condition of
the patient was improving, apart from this there were some
suggestions-
First line treatment for emphysema are antibiotics ( Beta lactum
antibiotics, Aminoglycosides and Macrolides) .
supplement (Syp. Zincovit) was given for low hemoglobin.
Metrogyl and linzolid was given for surgical prophylaxis.
12. Patient Counselling
Try to do some regular exercise or physical activity
that helps to improve breathing, ease symptoms and
have a better quality of life.
Try to avoid triggering factors like extreme hot or cold
weather.
Try to remain away from second hand smoking
exposure.
Adhere to the medications.
Maintain hygienic conditions.