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
Provisional diagnosis 

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

Popular posts from this blog

A 58 year old man presented with shortness of breath