A 57 Y/O MALE WITH FEVER, SOB AND VOMITING

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Consent and de-identification: The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being conserved entirely. No identifiers shall be revealed throughout this piece of work. 

Chief complaints:

A 57 y/o male, farmer by occupation, presented with chief complaints of generalised weakness, cough, shortness of breath, fever, loss of appetite, and vomiting since 5 days. 

History of presenting illness:

The patient was apparently asymptomatic 5 days ago,

→ then he developed generalised weakness and was unable to stand or walk

→ cough which is dry (non-productive)

→ shortness of breath which is of grade II - grade III

→ low-grade fever associated with sweating, and not associated with chills or rigors 

→ episodes of vomiting after consumption of food, which is non-bilious, non-blood stained, non-projectile, and not associated with abdominal pain

Past history:

The patient is a known case of diabetes since 4 years, treated with unknown medication. 

The patient is suffering from pain in the knees and lumbar region from 3 years, and is applying balms for relief. 

No h/o hypertension, tuberculosis, epilepsy, asthma 

Personal history:

Diet: mixed

Appetite: decreased

Bowel and bladder movements: regular

Sleep: adequate 

Addictions: regular alcohol consumption in the past, stopped 10 years ago

Family history:

No significant family history.

General examination:

The patient is conscious, coherent and cooperative, moderately built and nourished, and is well oriented to time, place and person. 

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Koilonychia: absent

Pedal edema: absent

Lymphadenopathy: absent

Vitals:

Temperature: afebrile

Respiratory rate: 25/min

Blood pressure: 110/80 mm Hg

Pulse: 105 bpm; rate, rhythm, volume, character normal, no radio-radial delay, no radio-femoral delay

Systemic examination:

Respiratory system:

Inspection:

Shape: symmetrical

No dilated veins, scars, nodules or sinuses present. 

JVP is not raised

Palpation:

Trachea: central

No intercostal tenderness

Percussion:

Left side: dullness present

Right side: resonant

Auscultation:

Normal vesicular breath sounds heard

No added sounds

Cardiovascular system:

S1, S2 heard

No murmurs

Gastrointestinal tract:

Abdomen: soft, non-tender, no organomegaly, umbilicus is not everted

Central nervous system:

Patient is conscious 

No weakness in the upper limbs

No paresthesias

No sensory disturbances in the lower limb

Lower limb tone, power: normal

Provisional Diagnosis:

Pleural effusion with collapse of left lung

Investigations:

Hemogram

Erythrocyte sedimentation rate 

Complete urine examination

Serum creatinine

Serum potassium 

Blood sugar - fasting

 Post lunch blood sugar

HBsAg - rapid

Liver function tests

Blood urea

Pleural sugar and protein

Pleural fluid LDH

LDH

ECG

Doppler 2D echo

USG chest

USG abdomen

Management:

Inj. NEOMOL (if temp > 101° F)

Tab. DOLO 650

Inj. OPTINEURON

Tab. ZOFER

Syp. GRILLINCTUS

GRBS monitoring 6-hourly

Vital charting 4-hourly

Inj. AUGMENTIN