THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THIS PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
EMR summary:
Diagnosis
PULMONARY TUBERCULOSIS SEQUELLE WITH INFECTIVE EXACERBATION; TYPE-1 RESPIRATORY FAILURE
Case History and Clinical Findings
CHIEF COMPLAINT: SOB SINCE 2 DAYS PRODUCTIVE COUGH SINCE 3 DAYS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN SHE DEVELOPED COUGH PRODUCTIVE, BLOOD TINGED (1 EPISODE) NON FOUL SMELLING AGGRAVATED ON COLD EXPOSURE, NO RELIEVEING FACTORS PT ALSO C/O BREATHLESSNESS SINCE 2 DAYS GRADE II MMRC ALSO WHEEZE AGGRAVATED ON COLD EXPOSURE AND ON EXERTION RELIEVED AT REST, NO C/O FEVER, CHEST PAIN, CHEST TIGHTNESS, PALPITATIONS
HIO LOSS OF APPETITE SINCE 10 DAYS
H/O LOSS OF WEIGHT LOSS PRESENT
H/O ADMISSIONS 3 TIMES FOR SIMILAR RESPIRATORY COMPLAINTS
H/O PTB IN 2015, USED ATT FOR 8 MONTHS
PAST HISTORY:
N/K/C/O DM, HTN, CAD, CVA, EPILEPSY, THYROID
NO HIO INHALER USE IN PAST
PERSONAL HISTORY
MARRIED, SISTER (NURSE), MIXED DIET, LOSS OF APPETITE SINCE 10 DAYS BOWEL AND BLADDER MOVEMENTS REGULAR
NO HIO ALCOHOL INTAKE, NO H/O SMOKING
FAMILY HISTORY:
NOT SIGNIFICANT
GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING OF FINGERS, PEDAL EDEMA, GENERALISED LYMPHADENOPATHY.
HEIGHT:158 CMS
WEIGHT:27 KGS
BMI:11.5 KG/M2
TEMPERATURE-AFEBRILE
PULSE-79 BPM
RR-20 CPM
BP-80/50 MM HG
SPO2-100%
GRBS-98 MG%
SYSTEMIC EXAMINATION:
CVS: $1, 02 HEARD
NO MURMURS
PER ABDOMEN: SOFT, NON TENDER
CNS NO FOCAL NEUROLOGICAL DEFICIT
RESPIRATORY SYSTEM EXAMINATION
INSPECTION:-
UPPER RESPIRATORY TRACT:-
NOSE-NO POLYPSINO DNS
ORAL CAVITY-NORMAL ORAL HYGIENE
POST PHARYNGEAL WALL-NOT INFLAMMED
LOWER RESPRIATORY TRACT-
SHAPE OF THE CHEST-ASYMMETRICAL
TRACHEA APPEARS TO BE SLIGHTLY DEVIATED TO RIGHT SIDE
CHEST MOVEMENTS APPEARS TO BE EQUAL ON BOTH SIDES
APICAL IMPULSE-NOT SEEN
APEX BEAT-NOT SEEN
NO SUPRACLAVICULAR HALLOWNESS AND INFRACLAVICULAR FLATTENING
NO USAGE OF ACCESSORY MUSCLES OF RESPIRATION
CROWDING OF RIBS PRESENT
WASTING OF MUSCLES PRESENT
NO DROOPING OF SHOULDERS
NO KYPHOSIS, SCOLIOSIS
NO SCARS, SINUSES, ENGORED VEINS, VISIBLE PULSATIONS
PALPATION:
NO LOCAL RISE OF TEMPERATURE
NO TENDERNESS
ALL INSPECTORY FINDINGS ARE CONFIRMED.
TRACHEA: DEVIATED TO RIGHT SIDE
CHEST MOVEMENTS EQUAL ON BOTH SIDES
APEX BEAT: FELT AT LEFT 6TH INTERCOASTAL SPACE AT MIDGLAVICULAR LINE
TVF: INCREASED IN RIGHT INTER SA
MEASUREMENTS:
AP-21 CMS
TRANSVERSE-16 CMG
RT 1-34 CMS E-33 CMS
LFT 1:35 CMS E-34 CMS
CC
I -68 CMS
E-67 OMS
PERCUSSION:
DIRECT-RESONANT OVER CLAVICLE AND STERNUM
INDIRECT-IMPAIRED NOTE IN LEFT MA, INTER SA
LIVER DULLNESS FELT FROM RIGHT 7TH INTERCOSTAL SPACE
CARDIAC DULLNESS WITHIN NORMAL LIMITS
AUSCULTATION
BAE+ -BBS IN RIGHT INTER SA. MA
4
BILATERAL CREPTS IN INTER SA, INFRA SA, IAA, ΜΑ
VR: INCREASED IN RIGHT INTER SA
GENERAL MEDICINE REFERRAL WAS DONE ON 13-8-25 IN VIEW OF METABOLIC ACIDOSIS AND WAS ADVISED
1. INJ. LASIX 10MG IV/STAT
GENERAL MEDICINE REFERRAL WAS DONE ON 17-8-25 IN VIEW OF NAUSEA WITH ABDOMINAL DICOMFORT, BLOATING AND WAS ADVISED
1. FLUID RESTRICTION
2. INJ. LASIX 10MG IV/STAT
NEPHROLOGY REFERRAL WAS DONE ON 17-8-25 IN VIEW OF METABOLIC ACIDOSIS AND WAS ADVISED
TO CONTINUE THE SAME TREATMENT ADVISED BY THE PRIMARY TREATING TEAM
COURSE IN THE HOSPITAL:
PATIENT CAME TO PULMONOLOY OP WITH COMPLAINTS OF PRODUCTIVE COUGH SINCE 3 DAYS AND BREATHLESSNESS SINCE 2 DAYS HISTORY OF LOSS OF APPETITE SINCE 10 DAYS NO HISTORY OF LOSS OF WEIGHT HISTORY OF PTB IN 2015 USED ATT FOR 2 MONTHS NO KNOWN COMORBIDITES. PATIENT ABG WAS DONE SHOWING TYPRI RESPIRATORY FAILURE AND STARTED PATIENT ON OXYGEN THERAPY CHEST X RAY WAS DONE SHOWING LEFT LOWER LOBE PNEUMONIA WITH OLD PTB CHANGES, PATIENT WAS STARTED ON BLBLI AND MACROLIDES FOR 5 DAYS AND FLUOROQUINOLONES FOR 1 WEEK, PATIENT WAS IMPROVED SYMPTOMATICALLY AND OXYGEN REQUIREMENT DECREASED.
Investigation
LFT (19-8-25)
TOTAL BILIRUBIN 0.72 MG/DL
DIRECT BILIRUBIN 0.19MG/DL
SGOT 14 IU/L
SGPT 10IU/L
ALP 158IU/L
TOTAL PROTEINS 7.0 GM/DL
ALBUMIN 3.1 GM/DL
A/G 0.79
RFT (19-8-25)
UREA 21 MG/DL
CREATININE 0.6MG/DL
URIC ACID 2.0 MMOL/L
CALCIUM 10.1MG/DL
PHOSPHOROUS 3.5MG/DL
SODIUM 138MMOL/L
POTASSIUM 3.5MMOL/L
CHLORIDE 98MMOLIL
Treatment Given (Enter only Generic Name)
1. INJ. AUGMENTIN 1.2GM IV/TID
2. INJ PAN 40 MG IV/OD/BBF
3. INJ. MVT IV/OD IN 100ML NG
4. TAB. PULMOCLEAR PO/BD
5. NEBG WITH DUOLIN 6TH HOURLY
BUDECORT 8TH HOURLY
6. IVF NS AT 50ml/hr
7. 7. INJ. MAGNEX FORTE 1.5GM/IV/BD
8. TAB. CIPROFLOXACIN 500MG PO/BD
9. INJ. OPTINEURON 1 AMPOULE IN 100 ML NS IV/OD
10. TAB. OROFER XT PO/OD/BBF
11. MONITOR VITALS ANFD INFORM SOS
Advice at Discharge
1.OXYGEN INHALATION 1-2 LIT/MIN TO MAINTAIN SPO2-94%
2.MDI.FORACORT 1 PUFF BD
3.TAB.PULMACLEAR PO/BO X 5DAYS
4.TAB.OROFER XT PO/OD
5. TAB.MVT PO/OD X 10DAYS
Follow Up
REVIEW AFTER 1 WEEK TO PULMONOLOGY OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient Attendent Declaration- The medicines prescnbed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:25/8/25
Ward: PULMONOLOGY
[27-08-2025 20:51] PPM 3: Of course. Here is a detailed summary and analysis of the provided Electronic Medical Record (EMR), structured for clarity.
### *Patient Summary*
This is the case of a severely malnourished female patient with a history of pulmonary tuberculosis (PTB), admitted for an acute infective exacerbation of her chronic lung disease and Type 1 Respiratory Failure. She was stabilized with antibiotics, bronchodilators, and oxygen therapy and discharged with close follow-up instructions.
---
### *1. Chief Complaint & History of Present Illness (HPI)*
The patient presented with a 3-day history of *productive cough* (one episode blood-tinged) and a 2-day history of *shortness of breath (Grade II MMRC)* and *wheezing. Symptoms were aggravated by cold exposure and exertion. She also reported a **significant loss of appetite for 10 days* and a history of *weight loss*. She had no fever, chest pain, or palpitations.
### *2. Past Medical History*
* *Pulmonary Tuberculosis:* Treated in 2015 with Anti-Tuberculosis Therapy (ATT) for 8 months (note: discrepancy in record, HOPI says 2 months, but history section says 8 months; 8 months is a standard duration).
* *Previous Admissions:* Three previous admissions for similar respiratory complaints.
* *Comorbidities:* No known history of diabetes, hypertension, heart disease, etc.
* *Social History:* Non-smoker, no alcohol intake.
### *3. Critical Clinical Findings*
* *Severe Malnutrition:* Weight 27 kg, Height 158 cm, *BMI 11.5 kg/m²* (Extremely and critically underweight).
* *Vitals on Admission:* Low BP (80/50 mmHg), normal pulse and respiratory rate. Oxygen saturation was 100% (likely on supplemental oxygen).
* *Physical Exam (Respiratory):*
* *Asymmetrical chest* with *tracheal deviation to the right*.
* *Wasting* of muscles and *crowding of ribs*.
* *Increased Vocal Fremitus (TVF)* and *Bronchial Breath Sounds (BBS)* in the right interscapular area, suggesting lung consolidation.
* *Bilateral crepitations* (crackles) in multiple lung fields.
* These findings are consistent with *post-TB sequelae* (lung scarring, fibrosis, and volume loss pulling the trachea) and a current *infective process*.
### *4. Key Investigations*
* *Arterial Blood Gas (ABG):* Revealed *Type 1 Respiratory Failure* (low oxygen levels).
* *Chest X-Ray:* Showed *left lower lobe pneumonia* superimposed on *old healed PTB changes*.
* *Blood Tests (LFT/RFT):* Largely within normal limits. Mild hypokalemia (K+ 3.5 mmol/L) was noted.
### *5. Hospital Course & Treatment*
The patient was diagnosed with *Pulmonary TB Sequelae with Infective Exacerbation and Type-1 Respiratory Failure*.
* *Oxygen Therapy:* Initiated to correct respiratory failure.
* *Antibiotic Regimen:* A broad-spectrum combination was used to cover common and atypical bacteria:
* *Inj. Augmentin (Amoxicillin/Clavulanic acid)*
* *Inj. Magnex Forte (Cefoperazone/Sulbactam)*
* *Tab. Ciprofloxacin (a Fluoroquinolone)*
* (Note: The macrolide mentioned is not listed in the final treatment list).
* *Bronchodilators & Steroids:* *Nebulization with Duolin (Levosalbutamol & Ipratropium)* and *Budecort (Budesonide)* to manage wheezing and inflammation.
* *Supportive Care:* Protein supplements (*Pulmoclear), multivitamins (MVT), Vitamin B complex (Optineuron), and iron (Orofer XT*). IV fluids and Pantoprazole for GI protection.
* *Consultations:* Referred to Medicine and Nephrology for metabolic acidosis and abdominal discomfort, managed with fluid restriction and a small dose of *IV Furosemide (Lasix)*.
### *6. Discharge Plan & Advice*
* *Continue Oxygen:* At 1-2 L/min to maintain SpO2 > 94%.
* *Medications:*
* *MDI Foracort (Budesonide/Formoterol):* For maintenance asthma/COPD-like management.
* *Tab. Pulmoclear:* Nutritional supplement.
* *Tab. Orofer XT:* Iron supplement.
* *Tab. MVT:* Multivitamins.
* *Follow-up:* Review in *Pulmonology OPD after 1 week*.
* *Emergency Instructions:* Contact the consultant or emergency department immediately in case of any emergency.
---
### *Summary Analysis*
This case illustrates a common and challenging scenario in pulmonology: a patient with *severe post-TB lung disease* experiencing an acute-on-chronic decline. The key factors are:
1. *Chronic Lung Damage:* The TB sequelae (fibrosis, bronchiectasis) create a permanent vulnerability to infection and airway obstruction.
2. *Acute Infection:* A new pneumonia (likely bacterial) triggered this exacerbation, leading to respiratory failure.
3. *Severe Malnutrition:* The critically low BMI (11.5) is a major red flag. It severely compromises immune function, respiratory muscle strength, and overall capacity to recover, significantly worsening her prognosis.
4. *Management:* Success involved treating the acute infection aggressively, supporting respiratory function with oxygen and bronchodilators, and attempting to address the profound nutritional deficit. The long-term outlook remains guarded due to the severity of the underlying lung damage and malnutrition.
[27-08-2025 22:09] PPM 2 Surely makes a case for Adrenal Insufficiency?
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