Pleural effusion
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
HISTORY OF PAST ILLNESS
TREATMENT HISTORY
FAMILY HISTORY
•No familiar history .
> PERSONAL HISTORY:
> Diet: mixed appetite: N.
> B/B: regular Sleep: Disturbed
> 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 (-)
> No Icterus and pallor
> B/l pedal edema
> No lymphaedenopathy
28/07/2021
General examination :
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, pedal edema,
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.
Systemic examination :
> Respiration:
> Inspection :
> Shape of the chestnormal
> Trachea appears to be central
> Nipples are at the same level
> No scars, sinuses, visible pulsations, engorged veins
> Palpation :
> No local rise of temp
> No tenderness
> Inspectory findings confirmed
> Chest expansion: at apex -equal on both sides
> At middle -decreased on left side
> On percussion :
> anteriorly: dull note observed from 6th ics on left side and from 5th ics on right side
> Infraaxillary-resonant on left right side and dull note from 6th ics on left side
> Posteriorly-resonant on rt side and dull note from 6th ics on lft side
> Auscultation :
> Bae+
> Breath sounds decreased on lft side.
> No adventitious sounds
INVESTIGATIONS
> LDH
> POST LUNCH BLOOD SUGAR:
> BLOOD SUGAR FASTING:
>GLYCATED HAEMOGLOBIN:
>PLUERAL {SUGAR,PROTEIN}:
PROVISIONAL DIAGNOSIS
sob secondary to plueral effusion.
TREATMENT
