60year old lady with complaints of chest pain and sob since yesterday morning

 3/03/2023

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Name: K. Thanmai reddy

Roll no: 76

60year old lady came to casuality with complaints of shortness of breath since yesterday morning

 chest pain since morning and

 dry cough since 2days

HOPI:

Patient was apparently asymptomatic 5months back later she developed swelling over right gluteal region and consulted doctor. For which she was diagnosed with peri anal abscess over the right side. She was treated conservatively with sitz bath and antibiotics(cotrimaxazole and metronidazole)

She also complained that she used to have fever on and off in past 5months and took tablet(dolo)

2days back (1/02/23) she developed dry cough at night which was insidious in onset and gradually progressive.

Next day morning (2/03/23) cough was  associated with shortness of breath(grade II to III) and chest pain.

Pt also complained of decreased urine output since yesterday.

PAST HISTORY:

N/K/C/O HTN,DM,CVA,ASTHMA,TB, EPILEPSY

Past surgical history: Rod implantation in both the thighs 10years back.

MENSTRUAL HISTORY:

Attained menopause 45years of age

PERSONAL HISTORY:

Occupation :she used to be farmer but later stopped working since 10years after undergoing rod implantation in both the thighs

Appetite decreased since 2days

diet mixed diet

Urine output decreased yesterday (2/3/23)

Bowel habits regular

No addictions

FAMILY HISTORY: 

 Insignificant

patient is conscious cooperative coherent well oriented to time place person 

Pallor present

No icterus, cyanosis, clubbing , lymphadenopathy, edema 

Vitals 

Temperature : 101°F

PR: 120bpm

RR:38cpm 

BP 140/90mmhg 

spo2: 96% at room air 

Systemic examination :

CVS: S1S2 heard, no cardiac murmurs heard 

RS: NVBS heard, 

P/A: Soft,non-tender

CNS : 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

INVESTIGATIONS:

Hb:8.4g%

TLC:25,300cells/cumm

PLATELET COUNT:4.19 laks/cumm

PCV:28.4

CUE:

SUGARS: NIL

ALBUMIN: 

BLOOD.UREA:120

SE.CRETAININE:3.8

SODIUM:122(2/3/23); 136(3/3/23)

CHLORIDE:104(2/3/23); 102(3/3/23)

POTASSIUM:6.1(2/3/23); 3.8(3/3/23)

IONISED CALCIUM:1.12(2/3/23); 1.07(3/3/23)

LFT:

TB:0.72mg/dl

DB:0.20mg/dl

AKP:444IU/L

TP:6.5gm/dl

ALBUMIN:3.0gm/dl

A/G RATIO:0.82

ECG:(03/03/2023)

2D-ECHO(03/03/2023)

EF:58%

TRIVIAL AR,MILD TR, NO MR,

No RWMA,NO MS,AS  MILD LVH

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION,NO PAH/PE

REVIEW 2D-ECHO

No TRIVIAL AR/ TR, NO MR,

No RWMA,MILD LVH,NO MS/AS 

Minimal PE, PLEURAL EFFUSION

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION,NO PAH/PE

USG ABDOMEN;

IMPRESSION:

Rt grade II RPD changes

Lt gradeIII RPD changes

Review USG CHEST

IMPRESSION:

Rt grade II RPD changes

Lt gradeIII RPD changes

Visualized collapsed bowel loops

No ascitis

USG CHEST:

E/O moderate free fluid in left pleural space with underlying lung collapse

E/O mild free fluid in right pleural space with underlying basal atelectasis

Impression:

B/L pleural effusion

REVIEW USG CHEST:(7/03/23)

B/L Pleural effusion(L>R)

MILD pericardial effusion

Diagnostic pleural tap done on (04/03/2023)

Cell count:2050

80% Neutrophilic

20%Lymphocytic

Therapeutic pleural tap done(80ml)

Total cells:400

80% Neutrophilic

20%Lymphocytic

 We have sent pleural fluid for ADA and report was 3.2. which was positive for TB

PROVISIONAL DIAGNOSIS:

PULMONARY TUBERCULOSIS 

TREATMENT GIVEN

03/03/2023

1. IV.FLUIDS NS  @100ML/HR

2.INJ.PIPTAZ 2.25GM 

3.INJ.LASIX 40MG IV/BD

4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

5.TAB.PCM 650MG PO/TID

6.T.NODOSIS 50MG PO/OD

7.T.OROFER-XT PO/OD

8.T.SHELCAL-CT PO/OD

9.NEB WITH DUOLIN 6TH HOURLY

04/03/2023

1. IV.FLUIDS NS  @100ML/HR

2.INJ.PIPTAZ 2.25GM 

3.INJ.LASIX 40MG IV/BD

4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

5.TAB.PCM 650MG PO/TID

6.T.NODOSIS 50MG PO/OD

7.T.OROFER-XT PO/OD

8.T.SHELCAL-CT PO/OD

9.SYP.ASCORYL

10.NEB WITH SALBUTAMOL 6TH HOURLY

(05/03/2023)

1. IV.FLUIDS NS  @100ML/HR

2.INJ.PIPTAZ 2.25GM 

3.INJ.LASIX 40MG IV/BD

4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

5.TAB.PCM 650MG PO/TID

6.T.NODOSIS 50MG PO/OD

7.T.OROFER-XT PO/OD

8.T.SHELCAL-CT PO/OD

9.SYP.ASCORYL

10.NEB WITH SALBUTAMOL 6TH HOURLY

06/03/23

1. IV.FLUIDS NS  @100ML/HR

2.INJ.PIPTAZ 2.25GM 

3.INJ.LASIX 40MG IV/BD

4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

5.TAB.PCM 650MG PO/TID

6.T.NODOSIS 50MG PO/OD

7.T.OROFER-XT PO/OD

8.T.SHELCAL-CT PO/OD

9.SYP.ASCORYL

10.NEB WITH SALBUTAMOL 6TH HOURLY

7/03/23

ANTI TUBERCULAR DRUGS for 6months

1.IV.FLUIDS NS  @100ML/HR

2.INJ.PIPTAZ 2.25GM 

3.INJ.LASIX 40MG IV/BD

4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

5.TAB.PCM 650MG PO/TID

6.T.NODOSIS 50MG PO/OD

7.T.OROFER-XT PO/OD

8.T.SHELCAL-CT PO/OD

9.SYP.ASCORYL

10.NEB WITH SALBUTAMOL 6TH HOURLY