viral pneumonia with pleural effusion

C/o fever since 10 days

SOB since 10 days.

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK, THEN DEVELOPED FEVER,HIGH GRADE A/W CHILLS AND RIGORS AND GENERALIZED BODY ACHES , SHORTNESS OF BREATH ON EXERTION.

NO H/O VOMITINGS, NO LOOSE STOOLS,NO CHEST PAIN

NO H/O BURNING MICTURITION,NO NECK STIFFNESS THEN PATIENT WAS TAKEN TO NEAREST HOSPITAL WHERE SHE GOT HRCT DONE. SHOWING B/L LOWER LOBE CONSOLIDATION.

GENERAL EXAMINATION: 

PATIENT IS C/C/C 

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY AND OEDEMA OF FEET.

VITALS: TEMP-99.   PR- 110.   RR-22.   BP- 100/70.   SPO2 -97%

OBG REFERRAL-

PROV DIAGNOSIS- 20 YEAR OLD G2P2L2A2 WITH  ?19WEEKS GA WITH 2 PREVIOUS LSCS WITH B/L CONSOLIDATION WITH ?VIRAL PNEUMONIA.

DIAGNOSIS-

VIRAL PNEUMONIA WITH B/L LOWER LOBE CONSOLIDATION WITH B/L MILD PLEURAL EFFUSION.

INVESTIGATIONS:

USG ABDOMEN- NO SONOLOGICAL ABNORMALITIES DETECTED

USG CHEST: B/L MINIMAL PLEURAL EFFUSION WITH CONSOLIDATORY CHANGES IN PERIPHERAL LUNG FIELDS.

USG ANTENATAL REPORT-

AFI-ADEQUATE

PLACENTA POSITION-ANTERIOR, 

MATURITY GR.-1

IMPRESSION- SINGLE UTERINE GESTATION OF ABOUT 17 WKS 5 DAYS.

TREATMENT GIVEN:

IVF. NS,RL@50 ML/HR

INJ.AUGMENTIN 1.2GM/IV/BD

INJ.AZOTHROMYCIN 500MG/OD

TAB.PCM 650MG PO/SOS

TAB.PAN 40MG PO/SOS

INJ.NEOMOL 1 GM/IV/SOS 

O2 INHALATION @ 4 LITRES/MIN

ADVICE AT DISCHARGE.:

REVIEW TO PULMONOLOGY OPD AFTER 1 WEEK.