A 48 old male came with complaints of chest pain and fever
48 Year old male toddy climber by occupation resident of kattangur came with chief complaints of
Fever since 7 days
Cough since 4 days
Chest pain since 4 days
Shortness of breath since 4 days
History of present illness
Patient complained of fever which was sudden in onset associated with chills relieved by medication.
4 days ago he also complained of drycough and shortness of breath progressed from grade 3 to grade 4.
He also complained of left sided chest pain dragging type aggravated by cough.
4 years ago History of similar episodes of fever and chills and got hospitalized where he was diagnosed with diabetes mellitus but on irregular medication.
He has history of seizures since 5 years 5 episodes in last 5 years.
Due to heavy alcohol intake he was hospitalized and was diagnosed with jaundice and fatty liver.
Last episode a year ago.
No history of orthopnea PND.
Past history
No history of Hypertension Tuberculosis Asthma CAD.
Family history
Not significant
Personal history
He takes Mixed diet
Appetite is normal
Bowel and bladder movements are regular
Addiction:Alcoholic since 20 years
Smoking- no
General examination
Patient is conscious coherent and coperative well oriented to time place and person
No signs of Pallor cyanosis clubbing lymphadenopathy
Icterus-+
Vitals
Afebrile
Bp 130/90
Respiratory rate 14 bpm
Pulse rate 72 bpm
Systemic examination
Respiratory system
INSPECTION
shape of the chest elliptical
No drooping of shoulders
Supraclavicular hollowness
No visible pulsation or scars
No crowding of ribs
PALPATION
Inspection findings are confirmed
Restriction of movement on left side of chest.
Trachea and apex beat are normal in position
No tenderness
No local rise of temperature
Vocal fremitus diminished on left side
PERCUSSION dullness noted inframammary area
AUSCULTATION
Normal vesicular breath sounds heard
No additional sounds heard
Vocal resonance increased
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness
No palpable mass
Liver not palpable
CNS EXAMINATION
Conscious ,alert
No motor deficit
No neck stiffness
No signs of meningeal irritation
Cvs examination
S1 s2 heard
No murmurs
Investigations
Repeat x ray
Report on 16/2/22
Diabetic ketosis secondary to sepsis
Irregular medication
Left Lower lobe consolidation
Treatment
Ivf RL NS
Inj Augmentin 1.2 gm iv tid
Inj Thiamine 1amp in 100 ml NS TID
Inj Zofer 4mg/iv/bd
8 am 2 pm 8pm
Inj. HAI 6 U - 6 U
NPH 6 U 6 U 6 U
Inj. Tramadol in 100 ml NS over 30 mins
Inj PCM
Syrp Benadryl 5ml/po/tid
Tab Cetirizine 5mg/po/od
Inj Azithromycin 500mg/po/bd
Comments
Post a Comment