50/M FEVER, COUGH WITH SPUTUM, CONTROLLED SUGARS

50/M FEVER COUGH WITH SPUTUM,UNCONTROLLED SUGARS

13/06/23

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CHIEF COMPLAINTS

The Patient came to hospital with the chief complaints of

* Cough since 8 Days

* Fever since 8 days

* Difficulty in breathing since 8 days. 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 8 days ago he then developed fever which is high grade and not associated with chills and rigors, evening rise is seen and is associated with sweating. 

There is history of Cough since 7 days associated with small amount of sputum, mucoid, blood tinged and is aggravated on changing the position from lying down to sitting position and also aggrevated during the night and no releiving factors. 

SOB grade - I MMRC 

7 days, aggrevating with cough, relieved on rest and not associated with wheeze. 

K/C/O: Diabetes mellitus diagnosed 2 years ago as an incidental finding during the orthopaedic surgery. 

H/o Road Traffic Accident 2 years ago

causing fracture neck of left femur with dynamic hip screw surgery done in another Hospital.

Immobilisation 1 1/2 to 2 years ago. 

H/o Electrocution 

7 years back causing burns on both the upper limbs. 

N/K/C/O Hypertension, CAD , Bronchial Asthma , Epilepsy. 

No H/O similar complaints in the past. 

No past H/O TB, loss of appetite, loss of weight. 

DAILY ROUTINE

Patient wakes up at 6 AM, he then freshens up and takes his diabetic medication glimiperide.

Drinks tea at 7 am, eats rice for his breakfast everyday at 9 AM and due to his Road Traffic Accident 2 years, had a fracture for which rod implant was done. Since then he is not working and stays at home because of the pain in his limb. 

At 1:00 pm he takes lunch i.e rice and walks a few steps in house then sleeps for an hour.

Eats dinner which is usually rice at 9:00 pm and goes to sleep by about 10:00PM.

PERSONAL HISTORY

Patient is an alcoholic for 11 years. 

 Smokes about 18 cigarettes a day for nearly 30 years. 

 He later started smoking Beedi Suttas.

It is significant to note that the patient's neighbour who also happens to be his son in low was diagnosed with Tuberculosis about 2 years ago. 

The Patient has been visiting him regularly & spends about 1 hour a  at every visit. 

Diet is mixed

PAST HISTORY

K/C/O Diabetes Mellitus since 2 years was diagnosed during his RTA treatment and is on regular Glimipride 1mg &Metformin 500mg medication since then.

He has no history of Hypertension , Diabetes , Asthma, Epilepsy, Tuberculosis.

GENERAL EXAMINATION 

Patient is conscious, coherent , cooperative and oriented to time , place and person. 

Slight pallor is seen. 

No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted. 

VITALS

Blood Pressure - 90/80mm Hg

Pulse Rate - 90 bpm

Respiratory Rate - 25 cpm

Temperature : 99.5 F

SPo2: 98%@RA

GRBS - 112 mg/dl

BURNS ON BOTH THE HANDS

SLIGHT DISCOLORATION ON THE LOWER BACK 

SURGICAL IMPLANT (L) LEG SCAR

INVESTIGATION

HRCT-CHEST

OBSERVATIONS:

The lung parenchyma

Thin walled cavity in apicoposterior segments of left lung upper lobe with surrounding consolidation.

Evidence of fungal ball within the above cavity.

Right lung field appears normal.

Pleura: No evidence of pleural effusion

Mediastinum No mediastinal lymphadenopathy.

Trachea, right main bronchus & left main bronchus: Appear normal.

The rib cage wall and dorsal spine: Normal.

Upper Abdomen: Right renal calculus.

Pancreatic calcifications consistent with chronic pancreatitis

Visualized portions of the liver, spleen, adrenals are unremarkable.

IMPRESSION:

Thin walled cavity in apicoposterior segments of left lung upper lobe with surrounding consolidation - Infective

 Evidence of fungal ball within the above cavity - Aspergilloma

 Pancreatic calcifications consistent with chronic calcific pancreatitis

URINE FOR CULTURE

SYSTEMIC EXAMINATION

CVS : S1 S2 heard , No murmurs heard . 

CNS : No focal neurological deficits . 

Respiratory system 

Inspection 

 

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

All inspectory findings are confirmed on palpation

 

Palpation 

 

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Decrs in infraclavicular area

 All areas move equally and symmetrically with respiration

Percussion 

 

Percussion Right Left

Supra clavicular: resonant resonant   

Infra clavicular: resonant Dull

Mammary: resonant Resonant 

Axillary: resonant resonant

Infra axillary: resonant resonant

Supra scapular: resonant resonant

Infra scapular: resonant resonant

Inter scapular: resonant resonant  

No tenderness

Percussion - Dull note on the left upper lobe 

Auscultation 

Auscultation: Right  Left

Supra clavicular:. NVBS NVBS

Infra clavicular: NVBS crepitations (fine)

Mammary: NVBS NVBS

Axillary: NVBS NVBS

Infra axillary: NVBS NVBS

Supra scapular: NVBS NVBS

Infra scapular: NVBS NVBS    

Inter scapular: NVBS NVBS

Respiratory rate - 20cpm 

Type of breathing : abdominothoracic

No supraclavicular hollowing or crowding of ribs seen, no visible sinus or scars

Tactile vocal fremitus Increased in the left upper lobe.

PROVISIONAL DIAGNOSIS

Pyrexia secondary to ? Pneumonia 

Pulmonary TB (?) 

With Anemia 

TREATMENT

IV Fluids@ 75ml /hr

Inj.Neomol 1gm IV/SOS (if temp more than 101 F)

Tab.Dolo 650mg PO/TID

Syp.Grillinctus dx 2tsp PO/TID

Inj HAI S/C TID ( acc to GRBS )

Inj Augmentin 1.2gm Iv/ BID until day 3 of admission 

Tab Itraconazole 200mg Po/Tid