On examination,
Vital signs:
BP: 124/72 mm Hg
PR: 88 bpm
T: 36.5
RR: 18
SpO2: 97% on nasal prong 3 L Oxygen
General Examination:
Patient looks comfortable, not in respiratory distress.
Noted there was finger clubbing and fine tremor
No pallor, cyanosis, edema
Lung examination:
No trachea deviation
Chest expansion reduced bilaterally
Vocal fremitus reduced
Percussion:
Auscultation: Air entry equal
Vesicular breath sound
Generalised expiratory rhonchi
Prolonged expiratory phase
No crepitations
Other systemic examination non- remarkable
Impression: Acute Exacerbation of COAD secondary to lower respiratory tract infection
Investigations:
Full Blood COunt:
Hb: 12
WBC: 6.5
Plt: 157
Differential:
Neut: 44.2
Lym: 42.4
Renal Profile
Urea: 7.5
Na: 135
K: 4.0
Creat: 72
Chest X-Ray:
hyperinflation at bilateral lung field, flattened diaphragm
reticulonodular shadowing at bibasal lung field.
Provisional Diagnosis: Acute exacerbation of COAD secondary to community acquired pneumonia
Plan:
1. Oxygen supplementation with face mask or nasal prong
2. IV fluids
3. Neb salbutamol with ipratropium bromide
4. IV hydrocorticotisone
5. Start augmentin and azithromycin for infection.
6. Monitor vital signs and SpO2 frequently
In-Ward
Management
1. 2-hourly
vital signs monitoring, then 4-hourly once stable
2. Keep
patient on nasal prong of 3L of oxygen.
3. Nebulised
Ipratropium bromide: salbutamol: normal saline at ratio of 2:1:1 4-hourly.
4. Tab.
Augmentin 1.2g STAT, then TDS
5. Tab.
Erythromycin 800mg STAT, then BD.
6. Tab.
Prednisolone 30mg OD.
7. Tab
Bisolven 8mg TDS.
8. MDI
Salbutamol 2 puffs PRN
9. MDI
Berodual 2 puffs TDS
To
assess MDI technique.Progress Notes:
Day 2- 3/3/2014
Currently
patient’s shortness of breath symptoms has improved. However patient still had
productive cough with yellowish sputum. Patient is able to tolerate orally. On
examination, Mr. S was still on nasal prong 3L of O2. Vital signs
were good. Patient was mildly tachpneic but was able to speak in full
sentences. On lung auscultation, there was good air entry. However, there was
still prolonged expiratory phase and generalised expiratory rhonchi. Medication
plan were continued. Patient’s technique of inhalation of MDI was assessed by
the pharmacist and was noted to be poor. Mr. S was counselled on the indication,
dose and frequency of MDI, technique and importance of compliance. Patient’s
technique was reassessed once again and was still noted to be poor. Pharmacist
suggest patient to buy an aerochamber.
Day 3- 4/3/2014
Mr.
S did not complain of any shortness of breath anymore. He was able to breathe
on his own without the aid of the nasal prong. Nasal prong was removed. SpO2
was 98% under room air. The steroid medication was changed to Tab Prednisolone
30mg OD and the rest of the medications were continued. Patient was not allowed
to be discharge due to lungs still having minimal generalised expiratory rhonchi
and prolonged expiratory phase.
Day 4-5/3/2014
Currently,
patient was comfortable and not tachypneic. Vital signs were good. There were
minimal generalised expiratory rhonchi. Patient was able to buy the aerochamber
and was taught by the pharmacist on the methods of using it. Patient was
allowed for discharged and a memo was written to KK for follow-up and review of
symptoms. He was also discharged with medications
1.
MDI Berodual 2 puffs TDS
2.
MDI Salbutamol 2 puffs PRN
3.
Tab Prednisolone 40mg OD X 2/7
4.
Tab Bisolven 8mg TDS
5.
Tab Augmentin 625mg BD X 4/7
Tab Erythromycin 800mg BD X 2/7
This format of writing notes is unsuitable for a house officer
ReplyDeleteSorry Dr. Vela! I was supposed to update it earlier on. I've edited and changed the progress notes. Do have a look and comment where possible. thank you! :)
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