A 35 year old with breathlessness since 8 days

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CASE

A 35 year old female,resident of miryalguda,worker in steel shop,came  with chief complaints of shortness of breathe since 8days

HOPI :She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigor,for which she went near local RMP and took injections and temperature decreased.

And then she developed breathlessness 8 days back,which was insidious in onset.SOB is of grade 2 and  history of orthopnea is present.SOB aggrevated on  exposure to dust and cool air,seasonal variation is present.

History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggrevated on lying in supine position and relieved gradually on sleeping to one side.

History of chest pain since 8days,which is dull aching type,radiating from left lower costal margin upward to back.No h/o tightness in chest, palpitations.

No h/o burning micturition,loss of weight.

PAST HISTORY:

Similar complaints 1 week back for which she went to local hospital in miryalguda,where investigations like chest x-ray and CT scan is done,showing large consolidations and ground glass opacities seen in the superior and posterior basal segment of left lower lobe of lung and small ground glass opacities seen in posterior basal segment of right lower lobe of lung.Suggesting of acute pulmonary infection(?viral pneumonia)

She is a known case of Asthma since 6years, which was aggrevated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.

She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.

She is not a known case of DM,HTN,TB,Epilepsy,CAD.

She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.

PERSONAL HISTORY:

Diet:Mixed 

Appetite:Normal and food taboos present for Brinjal as she belives that consumption may aggravate SOB.

Sleep: decreased since 8days  d/t chest pain.

Bowel,bladder:regular movements.

No addictions. 

FAMILY HISTORY :No significant family history.

Not allergic to any drugs. 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.

No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,edema appears on long standing and decreases on taking rest.

Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.

SYSTEMIC EXAMINATION:

PER ABDOMEN:Soft,non tender and organomegaly 

CNS:No focal neurological deficits.

RESPIRATORY SYSTEM:

-Upper respiratory tract:No DNS,Nasal polyp 

Oral cavity:Good oral hygiene.No loss of tooth/caries.

Posterior pharyngeal wall-normal.

-Lower respiratory tract:

On inspection:

Shape of chest: Elliptical,b/l symmetrical chest.

Chest movements equal on both sides.Spinoscapular distance equal in both sides.

No accessory respiratory muscles are used in respiration.

Apical impulse is not visible.

No scars, sinuses,engorged veins.

No kyphosis, scoliosis.

Trachea appears to be central.

Palpation:

No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.

Trachea-central position 

Apex beat-5th ICS medial to midclavicular line 

Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.

AP Diameter-30cms

Transverse diameter-34cms

Circumference-inspiratory-113cms, expiratory-110cms 

Right hemithorax- 55cms

Left hemithorax-56cms 

Percussion:

On direct percussion resonant note is heard 

On indirect percussion:impaired note in left ISA,IAA 

Auscultation:

Bilateral air entry present.

Decreased breathe sounds in left ISA,IAA. 

Cvs examination : s1 and s2 heard no murmurs heard.

Investigations:

On 26/12/2022,

Her ESR levels were 170mm in first hour

Neutrophilic count:81%

LFT:

Serum total bilirubin:1.1mg/dl

Serum direct bilirubin:0.4mg/dl 

C-reactive protein:61.7mg/l 

Chest x ray:

On 28/12/2022,

This is taken from local hospital in miryalguda.

CT CHEST done showing:

Large consolidations and ground glass opacities seen  in the superior and posterior basal segments of left lower lobe 

Small ground glass opacities seen in posterior basal segment of right lower lobe.

Suggesting of:Acute pulmonary infection l.(?Viral pneumonia)

On 29/12/2022,

On 03/01/2023,

This x-ray is taken in our hospital.

USG:

USG showing:

Left mild loculated pleural effusion and consolidatory changes noted in left basal segment.

PROVISIONAL DIAGNOSIS:

Non resolving pneumonia(clinically),with left lower lobe consolidation,with mild effusion on left lower lobe. 

Treatment:

On 03/01/2022,

Inj.CEFTRIAXONE-1gm,iv,bd 

Inj.PAN-40gm,iv,od.

Inj.NEOMOL-100ml,iv if temperature>101 

Tab.PARACETAMOL-650m,po,tid 

Syr.ASCORIL LS-2tsp,TID 

NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.

Tab.MONTEX LC,po,od 

On 04/01/23,

Investigations:

Inj.CEFTRIAXONE-1gm,iv,bd 

Inj. PAN- 40gm , iv, od.

Inj.NEOMOL-100ml,iv if temperature>101 

Tab.PARACETAMOL-650m,po,tid 

Syr.ASCORIL LS-2tsp,TID 

NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.

Tab.MONTEX LC,po,od 

Inj.LEVOFLOXACIN-750 mg,iv,od.

FOLLOW UP ON 5/1/2023

Follow up on 6/01/22: