General medicine case history

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A 67 yr old male patient presented to OPD with chief complaints of fever since 7 days and shortness of breath since 2 days

History of Present illness

Patient was apparently Asymptomatic 7 days back then developed fever and shortness of breath 

Fever:Low grade intermittent associated with chills and rigor

Shortness of breath: Grade 2 

Patient had visited to hospital in Nalgonda with the above complaints and investigations are done  HB-10.5 ,TLC 3000 , salmonella typhi O 1.320 salmonella typhi H 1.160   CXR- moderate to severe pleural effusion,thickened septa in right upper lobe

Past history 

Not a known case of DM,Hypertension,TB,epilepsy

Restricted Neck movements 

Family History 

No similar complaints in the family 

Personal History 

Diet : Mixed 

Appetite: Reduced since 1 week

Sleep : Normal

Regular Bowel and Bladder Habits 

Addictions:Occasional  toddy drinker but stopped 1 yr back

General Examination 

No pallor

No icterus

No cyanosis 

No lymphadenopathy 

No clubbing 

No pedal edema

Vitals

Temperature : Afebrile

Pulse Rate: 76 bpm

BP: 120/90 mm Hg

Systemic Examination 

CVS 

S1 and S2 heard

P/A 

Soft and non tender 

CNS 

Patient is conscious

Speech is normal

Provisional Diagnosis 

Viral Pyrexia with pleural effusion secondary to TB/CAP

Day 1

Pulmonology opinion is taken

USG chest,Dengue serology,sputum for AFB culture,serology for rtpcr advices

Inj Optineuron 1 amp in 100 mp NS IV/OD

Inj PANTOP 40mg iv/od 

Inj NEOMAL 1 amp in 100 ml

Tab PCM 500 mg

Inj Augmentin 1.2mg IV/BD

Tab azithromycin

CXR

Dengue rapid test

Haemogram

Serum creatinine 

USG chest

ECG

Fever chart

Investigation

Chest X-ray —

Shows right lower lobe consolidation 

USG chest —

e/o free fluid in Right pleural cavity with few internal echos -Right mild pleural effusion -e/o air sonograms in the peripheral R lower lung parenchyma suggestive of consolidation-no e/o fluid in pleural cavity-lung sliding sign+ deepest pocket 7-8 mm

Diagnosis: Viral Pyrexia (Dengue NS1+) with pleural effusion with right lower consolidation secondary to TB/CAP