A fifty nine years old male came to OPD with achie complaint of pain in the chest.
Date of admission: 24.07.2021
CHIEF COMPLAINTS:
> pain in the chest region during last 3 days
> distrubed sleep
HISTORY OF PRESENT ILLNESS
> patient was apparently started experiencing pain in the left side of the thoracic region since 3 days.
> No haemoptysis.
> No aggrevating.
> No diurnal variations.
> chest pain last three days , left sided, stabbing type , discontinuous.
> No radiation but distrubed sleep.
> No difficulty in takung respiration .
> No H/O PND attacks .
> No H/O Orthopnea.
> No H/O fever with evening rise.
> Noisy respirstion .
>NO H/O Trauma.
> NO H/O Inhaler usage.
> NO H/O Nasal / Ear discharge .
> NO H/O Recent hospitalization / Ventilation.
HISTORY OF PAST ILLNESS
> NO H/O similar complaints in past, HTN, DM, TB, epilepsy, chest pain & Bleeding disorders.
> NO H/O suggestive of Skin rash, Joint pains (Collagen Vascular Disorders).
TREATMENT HISTORY
> No H/O any surgical procedures / Long term treatment.
FAMILY HISTORY
•No familiar history .
> PERSONAL HISTORY:
> Diet: mixed appetite: N.
> B/B: regular Sleep: N.
> Addictions: smoker & occasional alchoholic .
> No drug allergies.
General Examination:
> (A) Physical examination Patient is C/C/C
P (-) I (-) C (-) C (-) & there is NO wrist tenderness K (-)
> L (-) NO cervical / Scalene LN palpable
> E (-) & There is No Signs of DVT / Erythema nodosum on legs
> N facies Moderately built & Adequately nourished
> Normal decubitus
> N voice & cough
>no Tobacco/nicotine staining.
> NO Flapping tremor.
> Eyes : Normal (No ptosis / contracted pupil / Subcj hemorrhage / Chemosis / ruddy cyanosis / Phlyctens)
> No Icterus and pallor
> B/l pedal edema
> No lymphaedenopathy
Vitals:
> PR :95 /min
> BP:130/80 mm of Hg .
> RR:22 cpm.
> Spo2 91 % on RA
>CVS:S1 S2 + ,no murmurs
>CNS - NAD
>P/A - soft
> R/S : decrease in B.sounds in infra scapular area.
> •TEMP 98.4°F.
INVESTIGATIONS
25/07/2021
> LDH
> POST LUNCH BLOOD SUGAR:
> BLOOD SUGAR FASTING:
>GLYCATED HAEMOGLOBIN:
>PLUERAL {SUGAR,PROTEIN}:
26/07/2021
> RFT
>LFT
>PLURAL FLUID [LDH]
>PLURAL FLUID [ADA]
PROVISIONAL DIAGNOSIS
sob secondary to plueral effusion.
TREATMENT
24/07/2021
> Tab Budecort 0.5mg { 2 repulses}[ 6th hourly]
>Tab Lasix [40mg]
> Tab Optineuron [strip of 10]
> T.pan [ 40mg]
> Syrup Aristozyme [bd]
> T.Telma [40 mg bd ]
> T. Glimi [M2]
25/07/2021
>T.Optineuron forte[ od]
>T Telma [40mg od ]
> T Glima [M2 od]
> T Pantop [40 mg od]
>NEB Budecort
> T Ultralet [1/2 po/qid]
> Syp Aristozyme[10ml po/tid]
>BP/PR/TEMP/RR- 4th Hour
> GRBS-6th Hour.
26/07/2021
>T. OPTINUERON FORTE [OD]
>T. TELMA[40mg OD]
>T.GLIMI-M2[OD]
>T. PNTOP [40mg /OD]
> NEB BUDECORT
> DUOLIN -5th hourly
> T .ULTRACET [1/2 PO/QID]
> SYP ARISTOZYME [10ml/TID]
> BP monitoring- 4th hourly
> GRBS- 6th hourly
27/07/2021
>T. GABAPENTIN [100mg] [14 days]
>T. ULTRACET [5 days]
>T.PENTOR[ 5 days]
>T. PANTOP
