40/M LEFT MODERATE PLEURAL EFFUSION SECONDARY TO TUBERCULOSIS WITH TYPE II DM

40 M CAME TO PULMONOLOGY OPD WITH

CHIEF COMPLAINTS:

C/O COUGH (DRY) :1 WEEK

C/O :FEVER: 7DAYSHOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK, LATER HE DEVELOPED INITIALLY COUGH WITH SPUTUM LATER NON PRODUCTIVE COUGH FOR WHICH HE GOT ADMITTED AND DIAGNOSED AS LEFT PLEURAL EFFUSION.NOW PRESENTLY WITH DRY COUGH SINCE 1 WEEK ,MORE IN THE NIGHT.NO AGGRAVATING AND RELIEVING FACTORS.

FEVER SINCE 1 WEEK,LOW GRADE EVENING RAISE PRESENT, SUBSIDED WITH MEDICATION.

NO COMPLAINTS OF CHEST PAIN, DECREASED URINE OUTPUT, SWEATING, PALPITATIONS.

H/O SIMILAR COMPLAINTS IN THE PAST FOR WHICH DIAGNOSED AS LEFT PLEURAL EFFUSION (TAP DONE 1500ML ON 23/3/23AND 25/3/23 AND SENT FOR PLEURAL FLUID ANALYSIS.

TC-5400,DC-100%L, PLEURAL FLUID ADA -41 IU/L, PLEURAL SUGAR - 211MG/DL, PROTIENS-5.4G/DL

NO H/O USAGE OF INHALERS IN PAST

NO ALLERGIC H/O

K/C/O DM ON GLIMESTER M1 FORTE BD 7YEARS

N/K/C/O HTN, THYROID,CAD.

SMOKER FOR 5 YEARS(1 BEED PER DAY)STOPPED SMOKING FOR 2 YEARS TOBACCO CHEWING 3 YEARS

GENERAL EXAMINATION:

PATIENT IS COHERENT, COOPERATIVE AND CONSCIOUS VITALS AT ADMISSION TEMP- 99 F

PULSE RATE - 102BPM

RESP RATE- 18CPM

BP- 120/80 MM HG

SP2 - 98% AT RA GRBS- 130MG/DL

WT - 67 KGS

RESPIRATORY SYSTEM:

AUSCULTATION-BAE+VE , NVBS +VE

DECREASED BREATH SOUNDS AT IAA, ISA.

Investigation

NEEDLE THORACOCENTESIS -3/4/23

UNDER STRICT ASEPTIC CONDITIONS BETADINE IS PAINTED AT LEFT HEMITHORAX ,2%

XYLOCAINE IS INJECTED AT LEFT 5 ICS AT MIDSCAPULAR LINE ,20CC SYRINGE IS INSERTED AT LEFT 5 ICSAND DRY TAP WAS ACHIEVED.

XYLOUNTL 10 INJELILU..

INSERTEWD AT LEFT 5 ICSAND DRY TAP WAS ACHIEVED.

USG ABDOMEN 3/4/23

GRADE 1 FATTY LIVER

LEFT MODERATE PLEURAL EFFUSION WITH INTERNAL ECHOES WITH MULTIPLE SEPTATIONS WITH UNDERLYING LUNG COLLAPSE

2D ECHO ON 3/4/23:

EF:65%

NO RWMA

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

ON 6/4/23 - GENERAL MEDICINE REFERAL WAS DONE IN VIEW OF DERRANGED LFT

ADVISED

1. INJ N ACETYL CYSTEINE 600 MG IN 100ML NS IV /STAT

2. CONTINUE UDILIV 300 MG PO/OD

ON 7/4/23 - GENERAL MEDICINE REVIEW WAS DONE

ADVISED

1. T.UDILIV 300MG PO/ BD

2. PROTEIN X POWDER IN 1 GLASS OF WATER OR MILK PO/BD ON - PSYCHIATRY REFERAL WAS DONE IN VIEW OF INSOMNIA

1 PATIENT AND ATTENDER COUNSELLED AND PSHYCOEDUCATED

2 SLEEP HYGIENE TECHNIQUES EXPLAINED

3 T. PREGABALIN-75MG P/O OD AT NIGHT

Treatment Given(Enter only Generic Name)

1.ATT(5 TABS/DAY)X 2 DAYS

2.T.BENADON 40MG PO OD

3. PAN D 40 MG PO OD BBF

4.T.PCM 650 MG PO SOS IF TEMP>100

5.SYP GRILLINCTUS DX 2TSBP PO TID

6.T.METFORMIN 1000MG+GLIMI 1 MG PO OD 8PM

7. T.UDILIV 300MG PO BD

8.HIGH PROTEIN DIET/2 EGGWHITES PERDAY

9. MONITOR VITALS /INFORM SOS

Advice at Discharge

1.TAB.ATT 5TABS/DAY

2.T.BENADON 40MG PO OD

3.SYP GRILLINCTUS DX 2TSBP PO TID

4.T.PCM 650 MG PO SOSIF TEMP>100

5.T.METFORMIN 1000MG+GLIMI 2MG PO OD 8AM

6.T.METFORMIN 1000MG+GLIMI 1MG PO OD 8PM

7. T.UDILIV 300MG PO BD

8.HIGH PROTEIN DIET/2 EGGWHITES PERDAY

OUTCOME COMPLETELY RECOVERED