34 yr old male ,farmer by occupation
A 34 year old male,resident of tangapally,nalgonda ,farmer by occupation presented to casuality with
H/O fever since 3 days associated with chills ,cough with expectoration yellowish in colour
Since 3 days
Sob
History of present illness :
Patient was apparently asymptomatic 6 months back he had history of chest pain - left sided for 2 days which subsided on medication (? Unknown )
Pt Stopped consuming alcohol for 1 month
History of fall from bike under influence of alcohol sustained injury to right clavicle and therefore had to stop going to work for 1 month .currently pt complains of History of high grade ,continuous type of fever since 3 days ,subsided on taking medication and on the next day fever was associated with chills and cough with expectoration - yellowish in color ,mucoid in constistency ,cold present (now subsided)
History of sob present ,grade 2 - 3 ( which made him come the hospital ) since 2 months which got aggravated from 4 days
No history of pedal edema,burning micturition ,decreased urine output
Past history :
Not a K/C/O DM,HTN,Asthma ,TB,epilepsy
No similar complaints in the past
No history of any surgeries or blood transfusions
Personal history :
Married
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel and bladder movements : regular
Alcohol consumption - daily 90 ml whiskey since 10 years
No history of smoking
O/E:
Pt is conscious,coherent and cooperative
Moderately built and nourished.
No signs of pallor,icterus , clubbing, cyanosis lymphadenopathy,edema
Vitals:
Afebrile to touch
BP: 140/70
PR: 116 bpm
RR: 28
Spo2: 95% on room air
CVS: S1,S2 heard
RS: vesicular breath sounds,left side inspiratory crepts in infrascapular area ,infra axillary area
Right side - decreased breath sounds in infrascapular area and infraaxiallary area
P/A: soft , non tender
Bowel sounds heard
CNS: normal
Provisional diagnosis : bilateral LL consolidation with pleural effusion ?CAP ?Viral pneumonia ?wet beri beri
Investigations :
HEMOGRAM :
Hb - 11.7
TLC - 8900
N - 70
L - 21
M - 07
E - 02
Pcv - 34.2
MCV - 80.7
MCH - 27.6
MCHC - 34.2
RBC - 4.24
Plt - 2.54
RFT :
Creatinine - 0.8
Urea - 13
Na - 139
K - 4
Cl - 97
LFT :
TB - 1.03
Db - 0.23
AST - 15
ALT - 23
ALP - 172
TP - 5.2
ALB - 3.3
A/G - 1.74
ECG :
Chest x ray :
ABG :
USG abdomen :
2d echo :
Treatment :
1) IVF - NS and RL @100 ml/hr
2) TAB .PCM 500 mg PO SOS
3) INJ.AUGMENTIN 1.25 GM/IV /BD
4)TAB.AZITHRAL 500 MG PO/OD
5) NEB with mucomist ,budecort @12th HRLY and asthalin @ 8th HRLY
6) Monitor vitals
Day 2 of admission :
S -fever spike @early mrng
cough present ,did not subside
Pain in suprapubic area ,no burning micturition
Last binge of alcohol 4 days back
O :
O/E:
Pt is conscious,coherent and cooperative
Moderately built and nourished.
Vitals:
Afebrile to touch
BP: 130/70
PR: 86 bpm
RR: 28 cpm
Spo2: 95% on room air
CVS: S1,S2 heard
RS: BAE + ,end inspiration coarse crepts in left infrascapular area, decreased breath sounds in right infra scapular region
P/A: soft ,tenderness in suprapubic area on deep palpation
Bowel sounds heard
CNS: normal
Assessment : bilateral LL consolidation ?CAP ?Viral pneumonia ?with bilateral pleural effusion (right >left )
?wet beri beri
Plan :
1) IVF - NS and RL with optineuron @100 ml/hr
2) TAB .PCM 500 mg PO TID
3) INJ.AUGMENTIN 1.25 GM/IV /BD
4)TAB.AZITHRAL 500 MG PO/OD
5) NEB with mucomist ,budecort @12th HRLY and asthalin @ 8th HRLY
6)INJ.PAN 40 mg IV/OD
7)INJ.THIAMINE 1 amp in 100 ml /NS /TID
8) SYP.BENADRYL P 10 ml/PO/TID
9)Monitor vitals