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38YEAR OLD MALE WITH RIGHT SIDED PLEURAL EFFUSION


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Team:

Interns-

Dr.Naga siva

Dr.Ruchitha pappula

Dr..Nimma siva


Dr.vaishnavi PGY1

Dr.Ajith Kumar PGY1

Dr.SushmithaPGY1

39/M presented with a

c/o  Right lower aspect chest pain since 1 month 

-HOPI-

Pt was apparently  asymptomatic 2 month back then he developed fever which is low grade intermittent with evening rise of temperature and relieved on medication

associated with dry cough lasted for 10 days 2months back relived on medication  

associated with  dyspnea, trepopnea  involuntary weight loss and loss of appetite. 

-Past history  

Edema of feet and abdomen which resolved in 2 days after admission in a out side  hospital. 


-Personal history 

Daily Alcohol Use for 20 years. Started with 90ml whisky eventually to 1 full bottle for the last 6 months and  Has not had alcohol for 2 months now as he has developed intolerance

o/E

pt was conscious,coherent,cooperative 

moderately nourished 


leuconychia +,mild pitting type  pedal edema. 

No signs of Icterus, cynosis, clubbing, lymphedenopathy

-vitals

temp-afebril,PR-85bpm,BP-100/70mmHg,RR-18cpm,spo2-98%at room air,GRBS-101mg/dl  Systemic Examination 

-cvs-s1,s2+,

-R/s

 Reduced Chest expansion on the right side (posterior > anterior) and stony dull note on percussion posteriorly and 4th ICS and below in the MAL. Absent breath sounds and decreased Vocal resonance and Vocal fremitus in the same areas. 


-P/A-soft , non tender,no organomegaly 

-CNS-NAD

Investigations


post diagonstic pleural tap

sputum CBNAAT
pleural fluid CBNAAT
Treatment 
on the day of admission 
1.INJ THIAMINE 100mg in 100 ml NS/IV/BD
2.INJ OPTINEURON 1AMP IN 100ML NS/IV/BD
3.TAB PCM 650 MG/PO/TID
4.TAB PREGABALIN 75MG/HS
5.INJ PAN 40MG IV/OD
DAY 1
1.INJ THIAMINE 100mg in 100 ml NS/IV/BD
2.INJ OPTINEURON 1AMP IN 100ML NS/IV/BD
3.TAB PCM 650 MG/PO/TID
4.TAB PREGABALIN 75MG/HS
5.INJ PAN 40MG IV/OD
DAY 2 
1.INJ THIAMINE 100mg in 100 ml NS/IV/BD
2.INJ OPTINEURON 1AMP IN 100ML NS/IV/BD
3.TAB PCM 650 MG/PO/TID
4.TAB PREGABALIN 75MG/HS
5.INJ PAN 40MG IV/OD
DAY 3
1.INJ THIAMINE 100mg in 100 ml NS/IV/BD
2.INJ OPTINEURON 1AMP IN 100ML NS/IV/BD
3.TAB PCM 650 MG/PO/TID
4.TAB PREGABALIN 75MG/HS
5.INJ PAN 40MG IV/OD
6. TAB Prednisolone 40mg PO/OD
7.TAB benfomate plus PO/OD
8. ATT 3drugs PO/OD
--Diagnosis - Right Sided Pleural Effusion with secondary to T

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