A 34yr OLD MALE PATIENT WITH SOB, SEVERE COUGH AND ANAEMIA
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A 34yr old male patient came with c/o shortness of breath (grade 2) and low grade cough since 20 days
patient is conscious,coherent,cooperative
C/o of severe cough,vomitings and diarrhoea
HISTORY OF PRESENT ILLNESS ：
patient was asymptomatic 20 days back then developed breathlessness. SOB (grade2) increased on exertion, relieved on taking rest, decreased on sitting position increased on lying down
After a week he developed intermittent fever during evening time along with vomitings and diarrhoea
Low grade cough
Loss of appetite
Loss of weight
PAST HISTORY
not K/C/O -DM, HTN, EPILEPSY, IHD
H/O bilateral leg ulcers 10 yrs back
PERSONAL HISTORY
Diet ：Mixed
sleep：adequate
bowel and bladder movements：regular
Alcoholic regularly
Habits : and chews tobacco
GENERAL EXAMINATION：
patient is concious,coherent,cooperative
Pallor :+ve
Icterus: -ve
Cyanosis: -ve
Vitals:
Tempearture ：Afebrile
PP：20CPM
PR: 98BPM
BP：110/80mmhg
SYSTEMIC EXAMINATION
CVS: S1S2 parsystolic murmurs
RS: breating sounds absent
P/A: soft non tender, BS +
INVESTIGATIONS
RBS: 98mg/dl
HbA1c: 6.5%
COVID-19 : -VE
ESR - 110
C
COLOUR DOPPLER 2D ECHO
COMPLETE BLOOD PICTURE
COMPLETE URINE EXAMINATION
SERUM IRON
SERUM UREA
SERUM CREATININE
DIAGNOSIS :
RIGHT SIDED EMPYEMA
Secondary to TB, CAP
ANEMIA
TREATMENT
INJ. PIPERCILLIN : 2.25g
Inj. Pantaprazole 40mg
Dextromethorphan syrup
Inj Metrogyl500mg TID
ascoril SYP. TID
