50years male with cough with sputum

 

50/M FEVER COUGH WITH SPUTUM,UNCONTROLLED SUGARS

June 08, 2023

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CHIEF COMPLAINTS

Patient came with chief complaint of cough since 

7 Days, Fever since 7 days, with difficulty in breathing since 7 days

HOPI

Fever since 7-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

NO H/O similar complaints in the past 

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

K/C/O: Dm+ since 2years 

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

- H/o -electrocution 
 4-years back - Burns both hands

PERSONAL HISTORY

Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day. 

Patient attendant said that their neighbour has TB ( who is son in law of him )

And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day

Patient started to have fever since 10 days at night time with burning sensation all over the body

Patient started to have unbearable pain at lower back  during cough .and always needed help from attendants to hold his back during coughing.

PAST HISTORY

K/c/o DM  since 2 years was diagnosed during his RTA treatment and is on regular Glimiperide 1mg &Metformin 500mg medication since then.

He has no history of  hypertension, diabetes ,asthma, epilepsy, tuberculosis.

GENERAL EXAMINATION 

Patient is conscious, cooperative ,coherent and oriented with time , place , date.
Slightly pallor, 
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:

Bp -80/40 mm Hg
PR-102 bpm
RR-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH

 

       

 Sputum sample:

       

 Burns in both hands: 

Slight discoloration on lower back:

Surgical implant (L) Leg scar:

INVESTIGATIONS

 06.05.2023

  07.06.2023

HRCT - Findings 

                            06.06.2023

HOPI

Fever since 7-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

NO H/O similar complaints in the past 

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

K/C/O: Dm+ since 2years 

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

- H/o -electrocution 
 4-years back - Burns both hands

SYSTEMIC EXAMINATION

CVS:S1 S2 heard , No murmurs 

CNS:

No focal neurological deficit

RS:
Breath movements -abdominal thoracic
In infra scapular area of left lung

Inspection: chest shape normal, 

Dysponea - present

Palpation: trachea -central

Auscultation: basal crepitations are heard

PROVISIONAL DIAGNOSIS

Fungal Ball Aspergilloma(?)

Cavitating pneumonia(?) TB (?) Uncontrolled Sugars (resolving)

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