42 year old female with viral pyrexia, left mild pleural effusion secondary to ?TB
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Chest Xray-
Name: Dr Sreshta J
42 year old female presented with complaints of
Cough since 1 month
Fever since 1 day
Hopi:
Patient was apparently asymptomatic 1 month ago then she developed cough which was dry and did not subside on medication
Patient had fever 1 month ago which was high grade, continuous, and it lasted for 1 week. Now she again has been having fever since 1 day which is high grade and continuous. Not associated with chills and rigors
Past history:
She's not a known case of diabetes mellitus, hypertension, asthma, epilepsy, TB.
Personal history:
Appetite - normal
Diet- mixed
Bowel and bladder movements- regular
Sleep- disturbed due to cough
No addictions
General examination:
Pallor yes
Icterus no
Cyanosis no
Clubbing no
Lymphadenopathy no
Generalised edema no
Malnutrition no
Temp- 101F
Bp- 110/80 mmHg
Pr- 139bpm
Rr- 26cpm
Spo2- 97% @RA
GRBS- 126mg/dl
Cardiovascular System : S1, S2 heard, no murmurs
Respiratory System : Bilateral air entry present. Position of trachea central. Decreased breath sounds in left IAA, mammary and interscapular areas
INSPECTION:
Chest appears bilaterally symmetrical
Respiratory movements appears equal on both sides
Trachea -Central in position
No scars ,Sinuses , Engorged veins and visible pulsations
PALPATION :
All inspectory findings confirmed
Trachea -Central
Apical Impulse - In Left 5th ICS
PERCUSSION:
Right Left
Supra Clavicular : Resonant Resonant
Infra Clavicular : Resonant Resonant
Infra mammary : Resonant dull
Axillary : Resonant Resonant
Infra axillary : Resonant dull
Supra scapular : Resonant Resonant
Inter scapular : Resonant dull
Infra scapular : Resonant Resonant
AUSCULTATION :
Right Left
Supra Clavicular : NVBS NVBS
Infra Clavicular : NVBS NVBS
Infra mammary : NVBS decreased
Axillary : NVBS NVBS
Infra axillary : NVBS decreased
Supra scapular : NVBS NVBS
Inter scapular : NVBS decreased
Infra scapular : NVBS NVBS
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact
Per abdomen : soft, non tender. No organomegaly.
Investigations:
USG chest-
USG abdomen-
ECG -
Pleural fluid protein/serum protein= 4.6/5.8= 0.7 →exudative
Pleural fluid LDH/serum LDH= 570/198.8= 2.8 →exudative
Pleural fluid LDH> 2/3rd of upper limit of serum LDH = 570> 306 → exudative
Lights criteria concludes that the effusion is exudative
Treatment:
IVF 1 DNS @75ml/hr
1 RL @75ml/hr
Inj Neomol 1 gm iv sos if temp >101F
Tab Dolo 650mg PO TID
Tab Pan 40mg PO OD
Monitor temperature and vitals 4th hourly
23/12/22 SOAP NOTES
42 year old female
GM unit 4
AMC bed- 5
Day - 1
S
Fever subsided
Cough subsided
O
Patient is conscious coherent and cooperative
Temp- 97.4F
Bp- 110/80 mmHg
Pr- 89bpm
RR- 20cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
Viral pyrexia with thrombocytopenia
P
IVF 1 DNS @75ml/hr
1 RL @75ml/hr
Inj Neomol 1 gm iv sos if temp >101F
Tab Dolo 650mg PO TID
Tab Pan 40mg PO OD
Monitor temperature and vitals 4th hourly
Pleural tap done
24/12/22 SOAP NOTES
42 year old female
GM unit 4
AMC bed- 5
Day - 2
S
Fever subsided
C/o difficulty in swallowing
O
Patient is conscious coherent and cooperative
Temp- 99.2F
Bp- 100/80 mmHg
Pr- 124bpm
RR- 22cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
Viral pyrexia
Left mild pleural effusion secondary to?TB
P
Inj Neomol 1 gm iv sos if temp >101F
Tab Dolo 650mg PO TID
Tab Pan 40mg PO OD
Monitor temperature and vitals 6th hourly
25/12/22 SOAP NOTES
42 year old female
GM unit 4
Ward
Day - 3
S
Fever subsided
Sob subsided
O
Patient is conscious coherent and cooperative
Temp- 98F
Bp- 110/70 mmHg
Pr- 126bpm
RR- 24cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
Viral pyrexia
Left mild pleural effusion secondary to?TB
P
Inj Neomol 1 gm iv sos if temp >101F
Tab PCM 650mg PO SOS
Tab Pan 40mg PO OD
Tab Limcee 500mg BD
Tab B complex OD
Chlorhexidine mouth wash TID
26/12/22 SOAP NOTES
42 year old female
GM unit 4
Ward
Day - 4
S
Fever subsided
Sob subsided
C/o difficulty in swallowing
O
Patient is conscious coherent and cooperative
Temp- 98F
Bp- 100/70 mmHg
Pr- 124bpm
RR- 22cpm
Cvs-S1 S2+
Rs- BAE+
Decreased breath sounds in left IAA, mammary and interscapular areas
CNS- HMF intact
P/a- soft, non tender
A
Viral pyrexia
Left mild pleural effusion secondary to ?TB
P
Tab PCM 650mg PO SOS
Tab Pan 40mg PO OD
Tab Limcee 500mg BD
Tab B complex OD
Chlorhexidine mouth wash TID
Syp Grilinctus 10ml PO BD
ENT referral i/v/o difficulty in swallowing
Adv- upper GI endoscopy for dysphagia evaluation
X-ray neck lateral view
27/12/22 SOAP NOTES
42 year old female
GM unit 4
Ward
Day - 4
S
Fever subsided
Sob subsided
C/o difficulty in swallowing
O
Patient is conscious coherent and cooperative
Temp- 98.2F
Bp- 110/80 mmHg
Pr- 124bpm
RR- 21cpm
Cvs-S1 S2+
Rs- BAE+
Decreased breath sounds in left IAA, mammary and interscapular areas
CNS- HMF intact
P/a- soft, non tender
A
Viral pyrexia
Left mild pleural effusion secondary to ?TB
P
Tab PCM 650mg PO SOS
Tab Pan 40mg PO OD
Tab Limcee 500mg BD
Tab B complex OD
Chlorhexidine mouth wash TID
Syp Grilinctus 10ml PO BD
FOLLOW UP:
After discharging from our hospital, patient consulted anothe doctor outside and was diagnosed as TB+
She's on ATT since.
Her complaints of cough, fever and difficulty in swallowing are resolved.
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