30 yr old female patient with Chief complaints of COUGH since 12 days & SOB since 4 days
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A 30 yr old female , is a labourer by occupation, resident of Nakrekal came to the OPD with chief complaints of
1. Fever since 15 days
2. Cough since 12 days
3. SOB since 4 days
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic 15 days back , then she developed fever
- insidous in onset
- low grade
- associated with chills & rigors
- & evening rise of temperature
For which she took medication at local hospital in Nakrekal . She was normal for 5 days and then again she is having fever (evng rise ) associated with
- dry cough since 12 days , 3-4 episodes per day, no nocturnal or diurnal variation
-Due to severe cough she is having chest pain, which increases in intensity on coughing , not radiating
- Cough is also associated with SOB since 4 days ( grade 4 - breathless at rest )
- No history of hemoptysis , palpitations, dyspnea on lying down or at midnight , pedal edema , decreased urine output
HISTORY OF PAST ILLNESS
No history of bronchial asthma , tuberculosis, hypertension, diabetes mellitus ,cardiac diseases, epilepsy, thyroid disorders .
TREATMENT HISTORY
She took medications for typhoid fever at local hospital in Nakrekal (10 days back)
FAMILY HISTORY :is not significant
PERSONAL HISTORY
Diet- mixed
Appetite - decreased
Sleep - inadequate
Bowel & bladder movements - normal
No addictions
MENSTRUAL HISTORY
She attained menarche at 13 yrs .She is having regular menstrual cycles of 30 days ,bleeds for 5 days & uses 2 pads per day .
GENERAL PHYSICAL EXAMINATION
Patient is conscious , coherent and co-operative , moderately built and moderately nosrished .
She is having mild pallor .
Icterus,cyanosis,clubbing,koilonychia,lymphadenopathy,edema are absent
VITALS
•Temperature - She is afebrile
•Pulse rate - 69 beats / min , regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
•Respiratory rate - 30 breaths / min
•Blood pressure - 90/60 mm Hg
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM EXAMINATION
I examined patient in sitting position
Inspection
•Symmetry of chest - elliptical
•Respiratory rate - 30 breaths / min
•Usage of accessory muscles for respiration
•Position of trachea - slight deviation to right( normal)
•No swellings , enorged veins , scars , sinuses ,
• No kyphosis & scoliosis
Palpation
Inspector findings are confirmed
No tenderness and no local rise of temperature over chest wall
Position of trachea - slight deviation to right ( normal )
Apical impulse - felt in 5th intercostal space in mid clavicular line.
Chest movements - decreased on right side
PERCUSSION
Dull note on right side (infra axillary , infraspinatous area )
AUSCULTATION
•Decreased breath sounds on right side
•Fine inspiratory crepitations heard (infrascapular)
•Bronchial breath sounds on right infra axillary , infraspinatous and infra mammary areas
CVS - S1, S2 heard , no added sounds and mumurs
CNS - Cranial nerves intact , reflexes intact , no cerebellar signs
PER ABDOMEN - soft non tender , bowel sounds heard
PROVISIONAL DIAGNOSIS
A 30 yr old female with right lower lobe consolidation ( Pneumonia )
TREATMENT
- IVF 1 unit NS 1 unit RL @75ml/ hour
- Inj. Augmentin 1.2gm/IV/BD
- Tab. Azithromycin 500mg/ PO/ BD
- Inj. Pan 40mg/ IV/ OD
- Inj. ZOFER 4mg/ IV/ SOS
- Inj. Optineuron 1 amp in 100ml NS / IV/ BD
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