For dry cough 60 years female

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Here is the full transcription of both handwritten notes:

Image 1 - Referral / Consultation Request

To, Prof, Asso. Prof, Asst Prof, SR on duty Department of General Medicine

Sir / Madam,

Pt of septic arthritis has rising temp, low O₂ saturation, hypotension, drowsy, respiratory distress. Please check the patient and evaluate.

Dr. Swastideepan 12.07.26 (For Dr. Golekh [draft])

Left margin annotation:

CXR - Non-homogeneous opacity on Rt. lung

Center:

TFR (Transfer)
Medicine Consultation done

Diagnosis:

Anemia, Pneumonia, Sepsis, Septic Shock

Image 2 - Prescription / Treatment Orders (Rx)

#	Drug	Dose	Route	Frequency
1	O₂ Inhalation	-	Inhalation	-
2	Inj. Piperacillin-Tazobactam (P+T)	4.5 gm in 100 ml NS	IV	TDS
3	Inj. Clarithromycin	500 mg	IV	BD
4	Inj. Primacort (Hydrocortisone)	50 mg	IV	Q6H (06 hourly)
5	Inj. NAC (N-Acetylcysteine)	600 mg	-	TDS
6	Inj. Human Albumin	20%	IV	OD
7	2 Units PRBC	to be given	-	-
8	Inj. Noradrenaline (Norad)	2 amp in 100 ml NS	IV infusion	@ 40 ml/min
9	Inj. Tramadol	50 mg	IV/IM	BD
10	Inj. Ondansetron (Ondem)	8 mg	IV	TDS
11	Inj. Pantoprazole (Pantoc)	40 mg	IV	BD
12	RTF (Ryle's Tube Feed)	200 ml x 05 feeds/day	-	-

Monitoring instructions:

I/O (Input/Output) monitor
Repeat Hb / Biochemistry
CBC on alternate days

Clinical summary: This is a critically ill patient with septic arthritis who has deteriorated into septic shock with multi-organ involvement - evidenced by hypotension (requiring noradrenaline vasopressor), respiratory distress/hypoxia (requiring O₂ + antibiotics for pneumonia on CXR), anemia (requiring PRBC transfusion), and hypoalbuminemia (requiring albumin infusion). The antibiotic regimen covers both the septic arthritis and co-existing pneumonia (Pip-Taz + Clarithromycin).

For dry cough 60 years female

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Here is a structured, clinically practical guide for treating dry cough in a 60-year-old female with no known cause identified yet.

Dry Cough in a 60-Year-Old Female - Treatment Guide

Step 1: Rule Out These First (Before Treating)

A 60-year-old woman with unexplained dry cough must have a chest X-ray first to exclude serious causes: lung cancer, TB, sarcoidosis, ILD. Do not skip this.

Also ask:

Is she on an ACE inhibitor (ramipril, enalapril, lisinopril)? - This causes dry cough in 5-30% of users and is the single most common drug cause. Stop it and switch to an ARB (losartan, telmisartan). Cough resolves in 1-4 weeks.
Symptoms of postnasal drip - throat clearing, sneezing, mucus sensation?
Symptoms of GERD - heartburn, regurgitation, worse on lying down?
Any wheeze or breathlessness? - cough-variant asthma?

Per Harrison's 22nd Ed., ACE inhibitors + postnasal drainage + GERD + asthma together account for the majority of chronic cough with a normal CXR.

Step 2: Treat Empirically by Most Likely Cause

Cause	First-Line Drug	Dose
ACE inhibitor-induced	Stop ACE inhibitor; switch to ARB	-
Post-nasal drip / Upper Airway Cough Syndrome	Intranasal fluticasone/mometasone	1-2 sprays/nostril OD
+ antihistamine (2nd gen)	Fexofenadine 120 mg OD or cetirizine 10 mg OD	for 6 weeks
GERD-related	Pantoprazole 40 mg or omeprazole 20 mg	OD before breakfast x 8 weeks
Cough-variant asthma	Inhaled salbutamol (SABA) + inhaled budesonide/formoterol	trial for 4-6 weeks
Eosinophilic bronchitis	Inhaled corticosteroid (budesonide 200 mcg BD)	6-8 weeks

Step 3: Symptomatic Cough Suppression (While Investigating)

When cause is unclear and cough is distressing, use antitussives:

Drug	Dose	Notes
Dextromethorphan 15-30 mg	Q4-6H	Safest OTC option; wide safety margin
Benzonatate 100-200 mg	TDS	May cause drowsiness/dizziness; swallow whole (do not crush)
Codeine 10-20 mg	Q4-6H	Effective but causes constipation; use short-term only
Levocloperastine	Per formulation	Less sedating alternative

Guaifenesin (expectorant) - NOT for dry cough; works for productive cough
Avoid first-generation antihistamines like chlorpheniramine as primary antitussives in elderly (sedation, anticholinergic effects)

Step 4: Refractory / Unexplained Chronic Cough

If all above causes are excluded and cough persists >8 weeks - consider cough hypersensitivity syndrome (neurogenic cough). More common in women and can last years.

Options per current evidence (Cleveland Clinic J Med, JACI In Practice 2024):

Drug	Dose	Evidence
Gabapentin 100-300 mg OD, titrate up	Off-label	Good evidence for chronic refractory cough
Pregabalin 75 mg BD	Off-label	Reduces cough sensitivity
Amitriptyline 10-25 mg at night	Off-label	Low dose, also helps sleep
Baclofen 10 mg TDS	Off-label	GABA-B agonist, reduces cough reflex
Gefapixant (P2X3 antagonist)	45 mg BD	Licensed in EU/UK/Japan; not yet widely available

Speech therapy / behavioral cough suppression - highly effective and should be offered alongside drugs.

Special Considerations for a 60-Year-Old Woman

Avoid strong sedating antihistamines (fall risk, cognitive effects)
Use lowest effective opioid dose and short courses only
Screen for osteoporosis if prolonged ICS use is planned
Menopause-related laryngeal changes can worsen cough sensitivity - consider ENT referral if hoarseness is present
If on amlodipine, note it rarely causes cough (far less than ACE inhibitors, but documented)

Bottom line: Start with CXR + check medication list (ACE inhibitor?). Treat empirically for post-nasal drip and GERD simultaneously while results are pending. Use dextromethorphan for symptomatic relief. If cough persists beyond 8 weeks with no identified cause, start low-dose gabapentin or amitriptyline for cough hypersensitivity syndrome.

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