A 45 years old female patient came to the casualty with chief complaints of Cough Breathlessness,Fever
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CHEIF COMPLAINT
A 45 years old female patient resident of narayanpur cook by occupation came to the casualty with chief complaints of:
Cough since 15 days
Breathlessness since 7days
Fever since 5 days
HOPI(History of present illness)
patient was apparently asymptomatic 15 days back then she developed cough(dry) insidious in onset,
no seasonal,diurnal,and postural variation,no aggrevating and relieving factors.
C/o breathlessness since 7 days ,grade II ,not associated with wheeze ,no seasonal diurnal variation ,no orthopnea ,no Paroxysomal Nocturnal Dyspnea
C/o fever since 5days low grade fever ,not associated with chills and regors , relieved with medication
No h/o chest pain,chest tightness,hemoptysis, palpation
PAST HISTORY:
No similar complaints in past
No h/o loss of wt and loss of appetite
No h/o TB,DM,HTN, bronchial asthma, epilepsy
No h/o inhaler usage in past
No allergic history
PERSONAL HISTORY:
Married
Occupation -cook
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
No addictions
No habit of betel nut, betel leaf , alcohol
FAMILY HISTORY:
No similar history in the family
Menstrual history 16 yrs regular 3-5 days every 28 days
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-No pallor
- No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of fingers
-No edema of feet
-No malnutrition
-No dehydration
▪️VITALS:
Temperature - 99F
Pulse rate - 106 bpm
Respiration rate - 20cpm
BP - 120/90 mmhg
SpO2 - 96% @ RA at 95% 6lit of O2
SYSTEMIC EXAMINATION:
▪️CVS
-no thrills
no cardiac murmurs
S1&S2 sounds are heard
RESPIRATORY SYSTEM
Respiratory examination:
INSPECTION:
UPRI- upper respiratory tract
Nose - no Deviated Nasal septum ,no hypertrophy, no nasal polyps
Oral cavity - no caries
No halitosis
Normal oral hygiene
LRTI -
INSPECTION:
Size and shape: chest is bilaterally symmetrical and elliptical
Trachea
Trail sign absent
No supraclavicular, infra clavicular hollowing
No usage of accesory muscles of respiration
Apical impulse is not seen
No crowding of ribs , dropping of shoulder,no wasting of muscles
Chest expansion appears to be decreased on left side
No kyphosis/scoliosis
No engorged veins , sinuses , scars , visible pulsations
PALPATION:
No local rise in temperature no tenderness
All inspectory findings are confirmed
Trachea: deviated to right side
Chest movement: reduced on left side
Measurement of chest expansion:
Anterior posterior diameter -24 cms
Transverse -21 cms
Right hemithorax-42cms
Left hemi thorax-44cms
CC:
I-82cm
E-80cm
Apex beat couldn't be palpated
Tactile vocal fermitus decreased in left side lung
PERCUSSION:
Direct- resonent-clavicle
Indirect-impaired dull note in left ISA IAA infraSA
Right left
Supraclavicular R R . Infraclavicular. R. R
Mammary. R. R
Axillary. R. R
Infra axillary. R. Dull
Suprascapular. R. R
Interscapula R. R
Infrascapular. R. Dull
AUSCULTATION:
Breath Sounds DECREASED IN left lung ISA, IAA ,infra SA ,ICA, MA
Vocal Resonance REDUCED IN left ISA IAA infraSA
Right. Left
Supraclavicular. N. N
Infraclavicular. N. N
Mammary. N. N
Axillary. N. N
Infra axillary. N Reduced
Suprascapular. N. N
Interscapular. N Reduced
Infrascapular N N reduced
▪️CNS
No nerological defect
Provisional diagnosis
Massive pleural effusion and viral pneumonia
Investigation
Treatment
Needle thoracocenthesis
Inj Cephtriaxone 1 mg IVbd
Pantaprozole
