medicine case discussion

50yr OLD MALE WITH FEVER,COUGH,VOMITING

March 29, 2022

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CHIEF COMPLAINTS:

50 year old male patient, toddy collector by occupation, resident of mothkur has come to with the chief complaints of 

1) Cough since 3 months 

2)Fever since 1 month

3)Vomitings since 5 days 

HISTORY OF PRESENT ILLNESS:::

Cough since 3months insidious onset gradually progressive wet with sputum yellow in colour ,foul smelling without blood stained.

Fever which is insidious in onset, gradual in progression with slightly rise in temperature at evening relieves on taking medications.

2 episodes of vomiting which was non bilious, non foul smelling

PAST HISTORY::

Around 7yrs ago

The patient weighing around 50 kg,was apparently asymptomatic 7 years ago

Then he had episodes of vomitings.He was taken to hospital where he was found out to be having Right sided pneumonia. He was prescribed some medications and advised to stop alcohol and smoking.

He took the medication for about 1 month strictly and he stopped alcohol and smoking for that course of time.

He got back to his addictions after 1 month.

The patient got back to his regular activities after 1 month

3yrs back

He stopped collecting toddy as his children and wife found out that he was consuming more amount of it

3 months ago

Wet cough with sputum which was 2-3 spoons full, yellowish, foul smelling without blood tinge.

Sputum is more in the morning and cough is more at night. He used to wake up from his sleep 

No medications were taken then

Since 1month

Fever which is insidious in onset, gradual in progression with no diurnal variation relieves on taking medications.

Diagnosed to be having Typhoid. Medications were prescribed but of no use.

The patient was weighing 35 kg around this time

Not a known case of DM HTN Asthama epilepsy 

Didn’t receive any blood transfusions or underwent major surgeries

FAMILY HISTORY 

Not significant 

PERSONAL HISTORY 

DIET- mixed

APETITE- decreased since 10 days

BLADDER MOVEMENTS - increased 

BOWEL MOVEMENTS- Regular

SLEEP- adequate 

ALLERGIES - no

Addictions::::h/o SMOKING since 30yrs

Daily 1pack of beedi

H/o alcohol consumption since 20yrs (250ml daily)

GENERAL EXAMINATION 

The patient is conscious coherent and cooperative, well oriented to time place and person

He is poorly built and poor nourished weighing 40 kg

Pallor- present

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema -absent 

VITALS

Temp- 99.6

Pulse rate- 98bpm

Rr- 16cpm

BP -110/70 mmhg 

RESPIRATORY EXAMINATION

INSPECTION

Accessory respiratory muscle movements- absent

Trachea- appears to be central

Apex beat- appears to be near the 5th inter coastal space

Supraclavicular hollow- present

Shoulder drooping - absent

Scoliosis/kyphosis/lordosis- absent

No engorged vein sinus or scars seen

PALPATION

All inspectatory findings have been confirmed

There is no rise of local temperature or tenderness

Trachea- central

Chest movements- Reduced on the right side

Vocal fremitus-reduced on the right side

Rib crowding - absent

Bong tenderness- absent

PERCUSSION

Right side dull note at mammary and inframammary areas

Left side resonant 

AUSCULTATION 

Right side - breath sounds reduced at right inframammary area

Left side - normal

No rhonchi or wheeze heard

INVESTIGATIONS 

CBP

RBS 146

Hba1c 6.5

Hb 7.58

TLC 9500

Neutrophils 90

Lymphocytes 4

Monocytes 3

Esinophils 3

Platlets 2.51lakhs

LFT

Total bilirubin 2.83

Direct bilirubin 1.25

AST 230

ALT 175

A/G 1.16

ALP 230

Total proteins 4.2

Albumin 2.26

SERUM ELECTROLYTES

28/03/2022

Na+ 132

K+ 2.4

Cl- 95

2D echo::

EF-55%

Trivial Tr+/no Mr , trivial Ar+

Good LV systolic function +

Diastolic dysfunction + 

USG abdomen : 

Findings: 1)E/O  air bronchogarm in right lung 

2)E/O 5 mm hyperechoic focus noted adherent to Gb wall 

Imp: 

1) Gall bladder wall edema 

2) right lung consolidation 

3)gall bladder wall polyp 

X-Ray 

Diagnosis::

 Hypokalemia with rt Lower lobe pneumonia

Hepatitis,acute gastroenteritis ,

TREATMENT

1)IVF.RL,Ns

2)Inj pantop 40 mg IV/od 

3)Inj zoefer 4 mg IV/sos 

4)tab udilin 500mg po/BD 

5)syp potklor 10 ml po/tid in glass of water

6)INJ monocef 1gm/IV/BD (day1)

7)2 scoop of protein powder in 100 ml milk/ water po/TID 

8)Ascoryl syrup po/TID 

9)monitor vitals  hourly