Ashok kumar- pleural effusion

CASE SCENARIO:-

A 32 yr old male came to casuality with Chief complaints of 

 Fever since 5 days

 Abdominal pain since 5 days 

chest pain since 5 days

 

HISTORY OF PRESENTING ILLNESS:-

[ ] Abdominal pain is pricking pain and continues since 1 week 

[ ] High Grade fever -intermittent from 6 days associated with chills

[ ] Dry cough since 1 day 

[ ] Body pains present with 6 days 

[ ] continues Headache since 6 days

PAST ILLNESS:-

No Tb,Asthma,D.M,HTN

FAMILY HISTORY :-

not significant

PERSONAL HISTORY:-

[ ] Married 

[ ] occupation-Daily wage worker

[ ] Appetite-Good

[ ] Bowel nd Bladder-Regular

[ ] Allergy-No

[ ] Addiction-No cigarette smoking 

                           chews tobacco pan masala once after 3 days

                           drinks Alchol Beer=90ml after dinner once in 3 days 

 

GENERAL EXAMINATION:-

[ ] Pallor- No

[ ] Icterus-No

[ ] Cyanosis-No

[ ] Lymphadenopathy-No

[ ] Edema-No

VITALS:-

Bp:120/80 mmhg 

Pulse rate:-80 bpm 

RR:- 18 cycles per min

Temp :- 98.7

Cvs :- s1,s2 heard no murmurs

Cns :- no focal neurological deficits 

Abdomen :- soft ,non tender 

Rs: decreased air entry 

SYSTEMIC EXAMINATION:-

INSPECTION-

        UPPER RESPIRATORY TRACT:-

[ ] Oral cavity- 

[ ] Oropharynx-

[ ] Chest appearance-

[ ] Respiratory movement-

[ ] Trachea position-

[ ] Dilated veins-

[ ] scars-

[ ] sinuses-

[ ] Visible pulsation-

PALPATION-

[ ] Trachea Position-

[ ] Apical impulse-

[ ] A.p - 21cm

[ ] Transverse-30 cm

INVESTIGATIONS:-

X-RAY:-

USG:-

ECG:-

Provisional diagnosis:

pain abdomen under evaluation 

Bilateral mild pleural effusion (right>left).

TREATMENT:-

T.PAN 40MG PO/OD

T.PCM 650 MG PO/TID

INJ.NEOMOL 1MG IV/ SOS

IV FLUIDS NS @50ML/HR

T.MYORIL 4MG PO/SOS

INJ.TRAMADOL 1 AMP IN100 ML NS/TID