18 year old came to casuality with chest pain and cough

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18year old male daily wage labourer (in rice husk factory) with chief complaints of
Fever since 10days
Associated with cold and cough
SOB on exertion
Right sided chest pain since yesterday night

HOPI - patient was apparently asymptomatic 10days back, then
- Developed fever (on and off) which was high grade and intermittent in nature. 
- Associated with cold, cough and sob on exertion
- Developed right sided chest pain since 2 days  which aggravated on inspiration - pleuritic pain
- H/o burning micturition present

PAST HISTORY - not a k/c/o DM /HTN /thyroid
Personal history -
Occupation : daily wage labourer (rice husk factory) 
Diet : mixed
Bowel and bladder movements : regular
VITALS - 
Temp : 101F
PR : 110bpm
RR : 24cpm
BP : 110/80mm Hg
Spo2 : 97% @ RA
No pallor/cyanosis/clubbing/lymphadenopathy/pedal edema

SYSTEMIC EXAMINATION - 
CVS : S1S2 +, no murmurs 
RS : BAE present, NVBS, FINE CREPTS + IN RIGHT INFRAMAMMARY AREA
P/A : soft, BS +
CNS : pt conscious, speech normal
CRANIAL NERVES : normal
INVESTIGATIONS 
ECG

TPR






Provisional diagnosis - ? LRTI : RIGHT LOWER LOBE PNEUMONIA

Treatment - 
1. IV fluids NS, RL @ 100ml/hr
2. Inj Augmentin 1.2gm IV/TID
3. Tab Azee 500mg OD
4. Inj Pan 40mg OD
5. Tab Dolo 650mg TID
6. Inj Neomol 1gm IV/SOS
7. Inj Optineuron 1amp in 100ml NS IV/OD
8. Syp Ascoryl 10ml TID
9. Monitor vitals

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