A 27 year old male presented to the OPD with fever and cough since 10 days

 A 27 year old male came to the OPD with complaints of fever associated with productive cough since nearly two weeks.

HOPI

Patient was apparently asymptomatic two weeks ago. Patient developed a fever 10 days ago which did not reduce with medication. Patient was taken to a clinic near his house where he received injections for the fever. When the fever did not subside, patient was brought to the hospital 5 days ago. Fever is of continuous type with diurnal variations.

Patient has associated cough which is productive with blood stained sputum. 

Patient also complains of left sided chest pain and pain along the left mid-axillary line since the onset of fever. 

Patient appears weak and mentioned that he breathes with difficulty. 

PAST ILLNESS

No H/O diabetes, hypertension, tuberculosis, asthma or epilepsy.

No previous surgeries.

No previous blood donations.

Patient was previously hospitalized twice: once for "stomach pain" 3 years ago, which reduced with medication; and once after a road traffic accident 6 months ago in which patient's jaw was injured. 

No relevant drug history.

FAMILY HISTORY

No significant family history.

PERSONAL HISTORY

Appetite-normal, mixed diet. 

Patient has disturbed sleep.

Normal bowel movements.

Patient has a habit of smoking, chewing tobacco since 5 years and drinks alcohol regularly.

Patient is said to be allergic to sour foods like tamarind. He is said to have experienced stomach ache following consumption of such foods.

Patient has not been vaccinated against COVID 19.

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative.

Poorly built. Patient is showing signs of cachexia (diffuse muscle wasting).

No pallor, icterus, cyanosis, clubbing or edema of feet.

VITALS

Temperature: 100.7 degrees Fahrenheit

Blood Pressure: 110/70 mm of Hg

Pulse rate: 111 beats per minute

Respiratory rate: 22 breaths per minute

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM 


Inspection

Shape of chest: normal

Symmetry of chest: Symmetrical

No visible scars, no sinuses or engorged veins

No deformities of spine

No visible apical impulse (the pulse at a point on the precordium farthest laterally and inferiorly from the sternum where the cardiac impulse can be felt.)

Palpation

No tenderness and no local rise of temperature.

Inspectory findings are confirmed.

Trachea is central.

Apex beat felt at 5th intercoastal space medial to mid clavicular line.

Vocal fremitus.

Percussion

No significant findings.

Auscultation

Bilateral air entry is present

Left side inspiratory crepts in IMA, IAA.

Egophony (Increased resonance of voice sounds heard during auscultation of lungs)


CVS
S1 and S2 heard.
No murmurs.

CNS
NAD

PA
Soft, non tender and no organomegaly.

INVESTIGATIONS







PROVISIONAL DIAGNOSIS
Diabetic ketoacidosis with left lobe pneumonia.


References:
https://pavangadila123.blogspot.com/2021/10/diabetic-ketoacidosis.html











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