39 year old female came with complaints of-Cough since 2 months (1 year,aggravated)Fever since 2 monthsChest pain and breathlessness since 2 months
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Unit 6:Case admitted in female ward on 6/2/2021.
Interns
K.Divya Rachana
K. Nikhil reddy
M. Swarna
B.Manivarma
Juveria
Dr. Vinay(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr.Praveen Naik( asst.proff)
A 39 year old female,deaf since birth and labourer by occupation came with complaints of-
Cough since 2 months (1 year,aggravated)
Fever since 2 months
Chest pain and breathlessness since 2 months
Patient was apparently asymptomatic 2 months,then she developed fever associated with chills and rigors, continuous type,relieves only on medication since 1 year.Chest pain since 2 months which is diffuse, increased on inspiration, gradually progressive and associated with breathlessness. Wheeze absent
H/O ?? tuberculosis in childhood
No H/O of DM,HTN, Thyroid dysfunction
On examination patient is conscious, coherent, cooperative
Afebrile
PR-86 beats per min, regular
BP-110/70 mm of hg
RS-
On inspection-
Right supra clavicular hollowness present, trachea appears deviated towards the right side,chest is bilaterally symmetrical,apex impulse not visible.
On palpation-
Trail's sign-positive,right SCM prominent,trachea deviated to right,chest expansion-1 cm,on inspiration 88 cm, on expiration 87 cm, Ap diameter of chest-14 cms , transverse diameter-22 cm,spinoscapular distance-8 cm,apex beat at 5th ICS mid clavicular line-TVF
On percussion- RT LT
SCA dull Resonant
Clavicular d R
ICA R R
Mammary R R
Axillary d R
IAA R R
Suprascapular d R
Interscapular. d R
Infrascapular R R
Kronigs isthmus d R
CVS- S1,S2 heard,no murmurs
P/A-soft,non tender,scaphoid,no organomegaly
Provisional diagnosis-
Right upper lobe fibrosis
Treatment-
Day 1-
Inj Augmentin 1.2 gm/IV/BD
Syp Grillunctus 2 tsp PO/TID
Tab Pcm 500 mg PO/SOS
Nebulization with Duolin 8th hrly
Nebulization with Budecort 12th hrly
Day 2
Inj Augmentin 1.2 gm/IV/BD
Tab Pan 40 mg PO/BD
Tab PCM 650 mg PO/BD
Thrombospas for left arm
Day 3-
Inj Augmentin 1.2 gm/IV/BD
Tab Pan 40 mg PO/BD
Tab PCM 650 mg PO/BD
Thrombospas for left arm
Syp Grillunctus 2 tsp PO/TID
Nebulization with Duolin 8th hrly
Nebulization with Budecort 12th hrly
Syp Mucaine gel 10 ml 20 mins before food
