Lavanya 19

Lavanya
Roll no .19
A 28 yr female patient resident of Surat came to OPD with chief complaints of left side flank pain, shortness of breath and dysuria.
Cheif complaint
Left side flank pain
Dyspnoea
One episode of hematuria and dysuria
History of present illness
Patient was apparently asymptomatic 15yrs ( i.e in 2007 ) she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT.and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria.
History of past illness
Hematuria,k/c/o tuberculosis in childhood
No h/o of diabetes , hypertension, epilepsy and no previous surgeries.
Personal history
Married
Appetite:normal 
Diet : mixed 
Bowels: irregular 
Micturition:normal 
Non alcoholic non smoker and no drug allergies
Family history
No f/h/o diabetes, hypertension,heart disease,asthma, tuberculosis.
Menstrual history
Irregular menstrual cycle
Physical examination
General examination
No palor
No cyanosis
No lymphadenopathy
No clubbing
No icterus
Vitals
Temperature:98.4F
Pulse : 76/ min
Respiratory rate : 14/min
BP: 120/80 mmHg
Systemic examination
Cvs
S1 S2 are present 
No thrills
No murmers
Respiratory system
Dyspnoea
No wheezing
Trachea shifted to right side 
Breath sounds : tubular
Abdomen 
Shape : scaphoid
No tenderness
Liver and spleen not palpable
Bowels sounds are present
CNS
Conscious
Speech : normal 
No neck stiffness and no kernigs sign
Sensory and motor system are normal 
Provisional diagnosis
Right upper lobe fibrosis secondary to old pulmonary tuberculosis .
Investigations
Treatment
TAB ULTRACET QID
TAB MVT PO/OD

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