NAME : BHUMIREDDY SASIDHAR REDDY

                                      ROLL NUMBER ; 20


 Hello all . This is sasidhar reddy, third semester medical student . this is an e lo depicting patient centered approach of learning. This log has been created after taking  concent from the patient and her family.

Introduction

A fifty nine years old male came to OPD with achie complaint of pain in the chest.

Date of admission: 24.07.2021

CHIEF COMPLAINTS:

> pain in the chest region during last 3 days 

> distrubed sleep

HISTORY OF PRESENT ILLNESS

> patient was apparently started experiencing pain in the left side of the thoracic region since 3 days.

> No haemoptysis.

> No aggrevating.

> No diurnal variations.

> chest pain last three days , left sided, stabbing type , discontinuous.

> No radiation but distrubed sleep.

> No difficulty in takung respiration .

> No H/O PND attacks .

> No H/O Orthopnea.

> No H/O fever with evening rise.

> Noisy respirstion .

>NO H/O Trauma.

> NO H/O Inhaler usage.

>  NO H/O Nasal / Ear discharge .

> NO H/O Recent hospitalization / Ventilation.

HISTORY OF PAST ILLNESS 

> NO H/O similar complaints in past, HTN, DM, TB, epilepsy, chest pain & Bleeding disorders.

> NO H/O suggestive of Skin rash, Joint pains (Collagen Vascular Disorders).

TREATMENT HISTORY 

> No H/O any surgical procedures / Long term treatment.

FAMILY HISTORY 

•No familiar history .

> PERSONAL HISTORY:

>  Diet: mixed appetite: N.

>  B/B: regular Sleep: N.

> Addictions:  smoker & occasional alchoholic .

> No drug allergies.


General Examination:

 > (A) Physical examination Patient is C/C/C

 P (-) I (-) C (-) C (-) & there is NO wrist tenderness K (-)

> L (-) NO cervical / Scalene LN palpable

> E (-) & There is No Signs of DVT / Erythema nodosum on legs

> N facies Moderately built & Adequately nourished

> Normal decubitus

> N voice & cough 

>no Tobacco/nicotine staining.

> NO Flapping tremor.

> Eyes : Normal (No ptosis / contracted pupil / Subcj hemorrhage / Chemosis / ruddy cyanosis / Phlyctens) 

> No Icterus and pallor

> B/l pedal edema

> No lymphaedenopathy 

                                                  28/07/2021

General examination :

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, pedal edema, 

Cvs : s1 s2 heard 
Per abdomen :soft non tender
Cns : intact

 Vitals: 

> PR :95 /min

> BP:130/80 mm of Hg .

> RR:22 cpm.

> Spo2 91 % on RA

>CVS:S1 S2 + ,no murmurs

>CNS - NAD

>P/A - soft 

> R/S : decrease in B.sounds in infra scapular area.

> •TEMP 98.4°F.

                                                     28/07/2021


Vitals: 

Bp: 130/80mmHg

PR: 95bpm

RR: 22cpm 

Spo2: 91%on room air.


Systemic examination :

> Respiration:

> Inspection :

> Shape of the chestnormal

> Trachea appears to be central

> Nipples are at the same level

> No scars, sinuses, visible pulsations, engorged veins

> Palpation :

> No local rise of temp

> No tenderness

> Inspectory findings confirmed 

> Chest expansion: at apex -equal on both sides

> At middle -decreased on left side

> On percussion :

>  anteriorly: dull note observed from 6th ics on left side and from 5th ics on right side

> Infraaxillary-resonant on left right side and dull note from 6th ics on left side

> Posteriorly-resonant on rt side and dull note from 6th ics on lft side

> Auscultation :

> Bae+

> Breath sounds decreased on lft side. 

> No adventitious soundsSystemic examination :

> Resp

> Inspection :

> Shape of the chestnormal

> Trachea appears to be central

> Nipples are at the same level

> No scars, sinuses, visible pulsations, engorged veins

> Palpation :

> No local rise of temp

> No tenderness

> Inspectory findings confirmed 

> Chest expansion: at apex -equal on both sides

> At middle -decreased on left side

> At base -decreased on left side

> On percussion :

>  anteriorly: dull note observed from 6th ics on left side and from 5th ics on right side

> Infraaxillary-resonant on left right side and dull note from 6th ics on left side

> Posteriorly-resonant on rt side and dull note from 6th ics on lft side

> Auscultation :

> Bae+

> Breath sounds decreased on lft side. 

> No adventitious sounds

INVESTIGATIONS 

25/07/2021

> LDH




> POST LUNCH BLOOD SUGAR:




> BLOOD SUGAR FASTING:




>GLYCATED HAEMOGLOBIN:






>PLUERAL {SUGAR,PROTEIN}:





26/07/2021

> RFT




>LFT




>PLURAL FLUID [LDH]




>PLURAL FLUID [ADA]




27/07/2021













PROVISIONAL DIAGNOSIS

The diagnosis was sob secondary to plueral effusion.

TREATMENT 

24/07/2021

> Tab Budecort 0.5mg { 2 repulses}[ 6th hourly]

>Tab Lasix [40mg]

> Tab Optineuron [strip of 10]

> T.pan [ 40mg]

> Syrup Aristozyme [bd]

> T.Telma [40 mg bd ]

> T. Glimi [M2]

25/07/2021

>T.Optineuron forte[ od]

>T Telma [40mg od ]

> T Glima [M2 od]

> T Pantop [40 mg od]

>NEB Budecort

> T Ultralet [1/2 po/qid]

> Syp Aristozyme[10ml po/tid]

>BP/PR/TEMP/RR- 4th Hour

> GRBS-6th Hour.

                                                                           26/07/2021


>T. OPTINUERON FORTE [OD]

>T. TELMA[40mg OD]

>T.GLIMI-M2[OD]

>T. PNTOP [40mg /OD]

> NEB BUDECORT

> DUOLIN -5th hourly

> T .ULTRACET [1/2 PO/QID]

> SYP ARISTOZYME [10ml/TID]

> BP monitoring- 4th hourly

> GRBS- 6th hourly


                                                                  27/07/2021


>T. GABAPENTIN [100mg] [14 days]

>T. ULTRACET [5 days]

>T.PENTOR[ 5 days]

>T. PANTOP


DISCHARGE SUMMARY:





















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