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 


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