50/M FEVER COUGH WITH SPUTUM,UNCONTROLLED SUGARS

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 15-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

K/C/O: Dm+ since 2years 


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

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 
No H/O similar complaints in the past 
No past H/O TB, loss of appetite, loss of weight

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 Glimipride 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












 





       INVESTIGATIONS


  







                          

                



























            










    


       







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



 

Popular posts from this blog

82 YR OLD FEMALE WITH BILATERAL LOWER LIMB WEAKNESS AND PEDAL OEDEMA

Image
une 20, 2023 82 year old female with B/l lower limb weakness and pedal edema. This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.  Chief complaints 82 year old female patient came with C/O weakness of lower limb, Neck and shoulder pain since along with pedal oedema and fever since 10 days. HOPI - Patient was apparently asymptomatic 10 days back then she developed weakness of the lower limbs, sudden in onset, non-progressive.  Also, C/O fever since 10 days low-grade not associated with chills and rigours, continuous, relieved on medication. C/O pedal oedema since 10 days, pitting type, from ankle to knee. No C/o chest pain, palpitations, cough, cold, LOC PAST HISTORY- K/c/o of HTN since 10 years(On medication- Telma 40mg) Not a k/c/o DM, Epilepsy, Seizures, CVA, Asthama, TB. PERSONAL HISTORY- Addictions- Nil.  Appetite- Normal Diet: Vegetarian  Sleep: Adequate  Bowel and bladder movements: R
Read more

A 35 year old female with headache and hearing loss

Image
A 35 year old female, resident of Nalgonda , farmer by occupation came to hospital on 19/9/22 with  CHIEF COMPLAINTS         Headache and neckpain since 6 months .  Headache was on and off and associated with vomitings. She complaints of hearing loss and tinnitus in right ear and giddiness since 1 month. HISTORY OF PRESENT ILLNESS        The patient was apparently assymptomatic 6months ago.The she had headache associated with neck pain and vomitings.  She complaints of hearing loss and tinnitus in right ear and giddiness while head movement since 1 month. She has no history of fever or chills. No history of ear discharge. PAST HISTORY        No history of DM       No history of HTN        No history of CAD , Asthma , epilepsy, TB  FAMILY HISTORY           No History of DM , HTN ,CAD , TB , Asthma  PERSONAL HISTORY         Married        Farmer by occupation        Mixed diet         Normal appetite        Normal bowel movement        Normal micturition        No known allergies    GENE
Read more

A 55 year old female with itching all over the body

Image
A 55 year old female, resident of Miryalaguda housewife by occupation came to hospital on 15/9/22 with  CHIEF COMPLAINTS        Itchy lesions all over of the body since 15 years . She complains of fever with pain with appearance of blisters . HISTORY OF PRESENT ILLNESS       The patient was apparently asymptomatic 15 years ago. Then she complains of itching all over her body associated with pain and fever and appearance of blisters. PAST HISTORY       No history of DM       No history of HTN        No history of CAD , Asthma , epilepsy, TB FAMILY HISTORY          A history of DM ,HTN         No History of CAD , TB , Asthma  PERSONAL HISTORY        Married        Farmer by occupation        Mixed diet         Normal appetite        Normal bowel movement        Normal micturition        Non alcoholic        Non smoker        No known allergies    GENERAL EXAMINATION         Conscious and coherent        Moderately built        Moderately nourished         No pallor        No icterus    
Read more