56 years old man with SOB

56 years old watchman by occupation came with the c.c of SOB grade 4 and left sided pain in the inframammamary area since 10 days.

History of present illness- Patient was apparently asymptomatic 10 days back. Then He developed SOB grade 2 which was insidious in onset, gradually progressive and progressed to the present  grade 4 in the last 3-4 days.

H/O Orthopnea present.

C/O Pain in left scapular area radiating to left side of chest since 10 days. Pain increases on cough.

H/O cough present since 1 week. Associated with mild sputum which  is non- blood stained.

C/O pain in the Right iliac fossa region on coughing. Not associated with tenderness.

No h/o chest pain

No h/o palpations

No h/o headache

No h/o loose stools, oliguria.

No h/o abdominal distension.

No h/o PND.

No h/o fever. 

Past h/o-H/O Asthma since 5 years. Exacerbated in winter season. Uses inhaler for Acute episode.

H/O TB 4 years ago. Used medication for 3-4 months.

Not K/C/O DM, HTN, Epilepsy, CVA, CAD.

Family h/o- Not significant 

Personal history- 

Diet- mixed 

Appetite- normal

Sleep- adequate

B&B movements- regular

Occasional toddy drinker 3 years back. Stopped since 3 years. 

No known allergies. 

General examination- 

No Pallor, icterus, cyanosis,clubbing,lymphadenopathy, pedal Edema.

Vitals-

Temp. - 98.2 F

PR - 82 bpm

RR - 16 cpm

BP - 130/80 mmHg

SpO2 - 99% at RA

O/E-

RS- BAE+, End Inspiratory wheeze present in all lung fields. Rhonchi present (Lt>Rt)

CVS- S1,S2 sounds heard. No murmurs

CNS- NAD

P/A- soft, non tender, bowel sounds present.

Investigations-

Hemogram-

Hb- 11.8 gm/dl

TLC- 16000 

Platelet count- 4 lakhs 

CUE-

Albumin- +

Pus cells- 3-6

Epithelial cells- 2-4

Serum creatinine- 1 mg/dl

ECG-

2D ECHO

USG-

CXR-

PROVISIONAL DIAGNOSIS-

PNEUMONIA WITH LEFT LOWER LOBE CONSOLIDATION.

OLD KOCH’S (INCOMPLETE ATT USAGE) 4 years ago. 

Treatment-

1)Neb. BUDECORT 6th hourly 

            IPRAVENT 6th hourly 

2)INJ. PANTOP 40 mg I.V. OD

3)INJ. AUGMENTIN 625 mg I.V. BD

4)TAB. AZITHRAL 500 mg PO/OD

5)TAB. PCM 500 mg PO/SOS

6)TAB. ULTRACET x 2 days

7)TEMPERATURE CHARTING 4th HOURLY AND TEPID SPONGING

8)STRICT I/O CHARTING

9)BP/PR/SPO2 CHARTING 4th HOURLY