60M SOB PAIN ABDOMEN

 A 60yr old male hailing from peddagattu,nalgonda district presented with complaints of fever since 6days and pain abdomen since 6days and shortness of breath since 6days.


He was apparently asymptomatic 6days back then he developed fever with chills associated with pain in right upper quadrant of abdomen.
No H/O vomitings.
No aggrevating or reliving factors.
H/O pain radiating to right chest and right shoulder region.
H/O burning micturation since 6days.
C/O cough since yesterday which is productive,whitish mucoid sputum,non blood tinged,non foul smelling
No H/O loss of weight,loss of apetite.

Past History:

No similar complaints in past.
Not a K/C/O DM,HTN,Asthma,Epilepsy,TB,CAD,Thyroid.
No significant surgical history.

Personal History:

Appetite is normal
Diet is mixed
Bowels are regular
Micturation is normal
Not known allergies
Habits-chutta smoking since 40years and 2chutta per day

FamilyHistory:

No relevent family history.

Physical Examination:

Patient is C/C/C
No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema

Vitals:

Temp:100.3F
PR:78bpm
RR:26cpm
BP:130/70mmhg
SPO2:97%@RA
GRBS:100mg%

PER ABDOMEN:
Inspection:abdomen obese all quadrants are moving equally with respiration
no scars,sinuses
Palpation:tenderness present in right upper quadrant of abdomen
murphy's sign is positive
No local rise of temperature
No organomegaly
Auscultation:bowel sounds are heard

CVS:S1S2 are heard
         No cardiac murmurs
RR:NVBS heard
      crepts are heard
CNS:NFND

DIAGNOSIS:

ACUTE CHOLECYSTITIS WITH PLEURAL EFFUSION.




















Date of admission:09/03/23
 
S
No c/o cough,shortness of breath,chest pain,chest tightness,hemoptysis,palpitations

O
Patient is c/c/c
Afebrile
PR:67bpm
BP:120/80mmhg
RR:20cpm
Spo2:94%on ra
cvs:S1S2 heard
      no cardiac murmurs
Rs:BAE Present
CNS:FNFD

A
RIGHT UPPER LUNG WITH RIGHT SYNPNEUMONIC EFFUSION TUBERCULAR ETIOLOGY ON ATT DAY2 WITH VESICAL CALCULUS WITH ESSENTIAL TREMMORS

P
INJ.AUGMENTIN 1.2GM IV TID
ATT (4TABS/DAY) ↓NTEP BBF
TAB.AZEE 500MG PO OD
TAB.PAN D 40MG PO OB BBF
TAB.BENADON 40MG PO OD
TAB.PCM 650MG PO OD
INJ.NEOMAL IV SOS IF TEMP>1O1F
TAB.BUSCOPAN PO OD
SYP.ASCORIL LS PO TID 2TBSP
SYP.CITRALKA 15ML PO BD


ATT STARTED ON 13-3-23 EMPIRICALLY 
CBNAAT NEGATIVE 
SPUTUM AFB NEGATIVE 
 PATIENT TOOK ATT FROM DEVARAKONDA AND NAGARJUNA SAGAR GOVERNAMENT HOSPITAL AND COMPLETED TREATMENT AND IS DOING FINE. HE WAS CONTACTED THROUGH PHONE AND FOLLOWED UP.

OUTCOME - COMPLETELY RECOVERED









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