A 56 yr old male presented with chief complaint of sob

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CHIEF COMPLAINT : 

56 yr old male patient complaints of SOB and pain over left inframammary area since 10 days and cough since 1 week.

HISTORY OF PRESENT ILLNESS: 

Pt was apparently asymptomatic  4 yrs back then he developed fever, chills , cough ,sob and pain in the left inframammary area and he consulted a doctor and  took medicine and symptoms are subsided 

Then now again he developed same symptoms 10 days back and cough since 1 week

Sob was gradually progressing and he had orthopnea. Pain increases on coughing . Cough is associated with sputum.

Daily routine : pt is a watchman by occupation . He gets up at about 5 o clock and takes breakfast by 7 o clock and go to his working place . And he takes his lunch at about 1 o clock and returns to his home by 5 pm and eat his dinner by 8 pm and go to bed by 9 30 pm . For 1 week he will have day duty and for 1 week he will have night duty till 12 am

PAST HISTORY : 

Pt had history of asthma since 5 yrs which will increase in winter season. And had a history of TB 4 yrs back and used medication for 3 -4 months.

Not a known case of DM , HTN, CVA, epilepsy

TREATMENT HISTORY : 

Pt uses inhaler for asthma.

PERSONAL HISTORY : 

Diet - mixed                                                            Appetite - decreased                                            Bowel and bladder movements - normal sleep - adequate                                  occasional toddy drinker stopped since 3 yrs   no habit of smoking 

FAMILY HISTORY : 

No relevant family history. 

DRUG HISTORY : 

Not allergic to any known drugs

GENERAL EXAMINATION: 

No pallor ,no icterus , no lymphadenopathy, no cyanosis , no clubbing , no  pedal edema.

 

Vitals : 

Temperature - afebrile

Respiratory rate - 16 cpm 

Pulse rate - 82 bpm

Blood pressure - 130 / 80 mm  Hg

SpO2 - 99% 

SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM: 

Bilateral air entry is positive .

CVS : S1 and S2 are heard . No murmurs                     heard 

CNS : no neurological deficits. 

ABDOMEN : soft , non tender , bowel sounds are present .

INVESTIGATIONS : 

Hemogram : 

 

CUE : 

ECG: 

X ray : 

PROVISIONAL DIAGNOSIS : 

Pneumonia and old Koch's with incomplete medication of ATT before 4 yrs .

 

TRATMENT : 

Neb . Budecort 6th hourly 

Inj. Pantop 40 mg IV .OD

Inj. Augmnetin 625 mg IV . BD 

Tab. Azithral 500 mg OD.

Tab. Paracetamol 500 mg PO

Temperature and vitals 4th hrly