A 54 year female presented with shortness of breath and pain in the right shoulder

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Here is a case i have seen:

 A 54 year old female presented with Shortness of breath since five days and complains of pain in right shoulder since six days.

 Patient was apparently asymptomatic six days back later she developed fever which is high-grade,sudden in onset, relieved with medication(paracetamol), associated with pain in right  shoulder ,which was noticed when doing her routine textile work which was gradual in onset, progressive, radiating to infra scapular infra axillary region, aggravated with exertion and not relieved with rest.

Sob since 5 days wheeze present ,gradually progressed from grade I to III.Sob increased on lying down and exertion.Relieved in sitting position.Diurnal variation present,Postural variation present.

Dry cough since 6 days

Loss of weight present.

 Patient had history of fall(2016) by slipping with weight lifted on right side ,following  she developed tingling and numbness of right upper and lower limb for six months, after which she had L5S, pedicle screw fixation + L5 laminectomy

Known case of asthma Since six years, used medication, stopped since five years.

Not a known case of hypertension, diabetes mellitus, CAD, CVA.

Personal history: 

Appetite: lost since 1 month

Bowels: constipation since 15 days

Bladder- burning micturition since 2 days 

No addictions

Family history:

History of DM

No history of  HTN, CAD, CVA, asthma   in the family

General examination: 

patient is conscious, coherent, cooperative 

Pallor is seen.

No icterus, cyanosis, clubbing,lymphadenopathy, edema

Vitals:

Temperature: 98.9F

Pulse: 86bpm

Respiratory rate: 19/ min

Bp: 130/80 mm of hg

Spo2: 98% at RA

Systemic examination: 

Respiratory system:Bilateral air entry present,NVBS,Decreased breath sounds over right infrascapular area.Right side crepts @ISA,SSA,InterSA.

Cvs: S1 S2 heard no additional sounds or murmurs.

Abdomen: soft,non tender

Cns: higher mental functions intact.

INVESTIGATIONS 

Day 1 chest xray

Day 2 chest x ray

Day 4 chest x charting

Day 6 xray

Treatment:

Day0:

1.Temperature charting

2.IVF 2RL}

       2DNS}@75 ml hr

3.BP,PR,RR,SpO2 charting 4th hourly

4.Inj.Optineuron 1 amp in 100 ml NS IV OD

5.INJ.neomol if temp>100 F

6.Tab Azithromycin 500 mg po od

7.Inj piptaz 4.5 gm iv stat 

                2.5 gm iv tid

8.Inj Tramadol 50 mg in 100 ml NS IV BD

9.Inj  Pan 40 mg iv bd

Day1:

1Inj.Optineuron 1 amp in 100 ml NS IV OD

2.INJ.neomol 1 g iv if temp>100 F

3.Tab Azithromycin 500 mg po od

4.Inj piptaz 4.5 gm iv stat 

                2.5 gm iv tid

5.Inj Tramadol 50 mg in 100 ml NS IV tid

6.Inj  Pan 40 mg iv bd

7.IVF 2 RL 

          2 DNS @100 ml/hr

8.Temperature charting

9.BP,PR,RR,SpO2 charting 4th hourly

10.I/O charting

Day2:

1Inj.Optineuron 1 amp in 100 ml NS IV OD

2.INJ.neomol 1 g iv if temp>100 F

3.Tab Azithromycin 500 mg po od

4.Inj piptaz  2.5 gm iv tid

5.Inj Tramadol 50 mg in 100 ml NS IV tid

6.Inj  Pan 40 mg iv bd

7.IVF 2 RL 

          2 DNS @100 ml/hr

8.Temperature charting

9.BP,PR,RR,SpO2 charting 4th hourly

10.I/O charting.

Day 3:

1.Inj.Optineuron 1 amp in 100 ml NS IV OD

2.INJ.neomol 1 g iv if temp>100 F

3.Tab Azithromycin 500 mg po od

4.Inj piptaz 4.5 gm iv stat 

                2.5 gm iv tid

5.Inj Tramadol 50 mg in 100 ml NS IV tid

6.Inj  Pan 40 mg iv bd

7.IVF 2 RL 

          2 DNS @100 ml/hr

8.Temperature charting

9.BP,PR,RR,SpO2 charting 4th hourly

10.I/O