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Introduction
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 :
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 roomair
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
Cvs : s1 s2 heard
Per abdomen :soft non tender
Cns : intact
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]
Pleural fluid cell count:
CELL COUNT: VOL- 2.5 ML
APP-N PALE YELLOW
CLEAR
TC- 425 CELLS
DC - 80 % LYMPHOCYTES ,20 % NEUTROPHILS
RBC - FEW
PROVISIONAL DIAGNOSIS
LEFT PLEURAL EFFUSION WITH K/C/O HTN AND DM 2 WITH ?HFREF
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
SOB DECREASED
o/E PT IS C/C/C
AFEBRILE
PR 95
BP: 130/80
RR 22CPM
CVS: S1 S2 HEARD
CNS INTACT
R/S :DECREASED BREATH SOUNDS IN INFRA AXILLARY AND INFRASCAPULAR REGION ON LEFT SIDE
P/A SOFT
Rx
>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
Complaints of low back ache ,SOB subsided
o/E PT IS C/C/C
AFEBRILE
CVS: S1 S2 HEARD
CNS INTACT
R/S :DECREASED BREATH SOUNDS IN INFRA AXILLARY AND INFRASCAPULAR REGION ON LEFT SIDE
P/A SOFT
Rx
>T. OPTINUERON FORTE [OD]
>T. TELMA[40mg OD]
>T.GLIMI-M2[OD]
>T. PANTOP [40mg /OD]
> NEB BUDECORT or DUOLIN -6th hourly
> T .ULTRACET [1/2 PO/QID]
> SYP ARISTOZYME [10ml/TID]
> BP monitoring- 4th hourly
> GRBS- 6th hourly
>Tab. ECOSPIRIN AV 75/10 OD
>Tab Lasix 40 mg po od
27/07/2021
Complaints of low back ache ,SOB subsided
o/E PT IS C/C/C
AFEBRILE
PR 84
BP: 140/90
CVS: S1 S2 HEARD
CNS INTACT
R/S :DECREASED BREATH SOUNDS IN INFRA AXILLARY AND INFRASCAPULAR REGION ON LEFT SIDE
P/A SOFT
Rx
>T. OPTINUERON FORTE [OD]
>T. TELMA[40mg OD]
>T.GLIMI-M2[OD]
>T. PANTOP [40mg /OD]
> NEB BUDECORT or DUOLIN -6th hourly
> T .ULTRACET [1/2 PO/QID]
> SYP ARISTOZYME [10ml/TID]
> BP monitoring- 4th hourly
> GRBS- 6th hourly
>Tab. ECOSPIRIN AV 75/10 OD
>Tab Lasix 40 mg po od
DISCHARGE SUMMARY:
