GM Blog: 48 year old male patients

48 yr old male patient

NOTE

This is an ongoing case and will be updated 

The reference link (if any) will be mentioned at the bottom.

Date of admission: 12/02/22

CHIEF COMPLAINT-
Patient came to the OPD with complaints of chest pain (since yesterday) with fever, cough and cold from 3 days.

HISTORY OF PRESENT ILLNESS- 

Pt was apparently asymptomatic 4 days back then developed fever - high grade associated with chills,rigor and cough.
C/o dry cough , aggrevates at night 
C/o 1 episode of vomiting associated with food particles 1 day back 
Pt had similar complaints of fever associated chills and rigor in the past since 5 years
4 years back pt got hospitalized with fever and chills and got diagnosed with DM
In past 5 years , pt had 5 - 6 hospital admissions with similar complaints due to heavy drinking and got diagnosed with fatty liver and jaundice.
H/o seizures since 5 years 
4 - 5 episodes in last 5 years , with gap of 1 year in between the episodes .
Last episode - 1 year back 
Tongue bite + , Remains in unconscious state for 5 mins
H/o covid + 1 year back 
Received 1 dose of vaccine - covishield 


Daily routine before : 
The patient was apparently asymptomatic 4 years ago when he used to work as a toddy tree climber.
He used to get up early morning and go for work after having breakfast and work till 9pm.
Daily routine after (since 4 yrs):
The patient is mostly staying at home and taks alcohol everyday.

PAST HISTORY:
history of tuberculosis 4 years back ( used ATT for 6 months ) 
HYPERTENSION since 1 month
no history of  CAD ,asthma
no history of surgeries, radiation ,blood transfusion

PERSONAL HISTORY:
Married 
Occupation : toddy tree climber
Diet: mixed. ( Non vegetarian)
Appetite: normal
Sleep: Adequate
Micturition: Regular
Habits/ addictions
Chronic alcoholic since past 30 years 
Heavy drinking since past 10 years ( 360 - 480 ml/day )
Pt went to rehabilitation for 1 year ,but never stopped drinking

FAMILY HISTORY:
Not significant 


GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
He is thin built. 
Pallor - absent
No icterus
No cyanosis
No clubbing
No Edema 
No Lymphadenopathy 

VITALS :  

Temp : Afebrile 
Pulse Rate : 92 bpm
Blood pressure : 120/80 mmhg 
Respiratory Rate : 22 /min
SPO2 : 88 % at RA 


SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  

S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : 
Shape of chest: normal
Position of trachea: normal 
dyspnoea present
Breath sound : vesicular 
Bilateral air entry present , on auscultation wheeze + 

CNS : 
Level of consciousness: alert
Speech: normal
No abnormality detected

ABDOMINAL EXAMINATION:
non tender 
Soft
No palpable mass
Liver and spleen : non palpable


INVESTIGATIONS :
    












Repeat x ray 15/2/22 : 


Psychiatry referral done on 15/2/22 :

Pulmo referral: 


BAL performed on 19/2/22

 

PROVISIONAL DIAGNOSIS: 
Diabetic ketosis ( resolved ) secondary to ? sepsis 
? Irregular medication 
With ? Left Lower lobe consolidation 
With cholelithiasis 
With DM since 4 years 
With Alcohol dependence 

TREATMENT: 

1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
  Inj. HAI 8 U - 8 U
        NPH 10 U 10 U 10 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. TusQ D capsule 
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Tab. PCM 650 mg/po/TID x 3 days
15. Tab. Naproxen 250 mg /po/ BD x 3days





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