A 48yr old male pt with cough and chest pain

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ICU bed 2 

A 48 y / male who is toddy tree climber by occupation since past 30 years,

came with complaints of

 chest pain since 4 days

 fever, cold and cough since 7 days. 

HOPI : 

Pt was apparently asymptomatic 7 days back then developed fever - high grade associated with chills and rigor , on and off , relieves with medication.

C/o dry cough which aggrevates at night 

C/o SOB due to excessive coughing,

  orthopnea  - , PND - 

C/o 1 episode of vomiting associated with food particles 1 day back - non bilious

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 , on OHA ( met formin hydrogenchloride po/od ) - irregular medication.

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 multiple RTA s with minor injuries over left hand, left knee, right eye, right ankle

H/o covid +  1 year back 

Received 1 dose of vaccine - covishield 

PAST HISTORY:

not a known case of HTN,TB,ASTHMA,CAD

Known case of diabetes since 4 yrs

PERSONAL HISTORY: diet-mixed 

appetite-normal

Sleep-disturbed due to cough and pain

B&B-regular

Addiction- chronic alcoholic since 30yrs

Heavy drinking since past 10yrs

Pt was sent to rehabilitation for 1yr but he never stopped drinking

GENERAL EXAMINATION: 

Pt is conscious, coherent, cooperative

Well oriented to time , place and person

Pallor - 

Icterus  -

Cyanosis - 

Edema of feet - 

Lymphadenopathy  - 

Clubbing -

VITALS :  

Temp :  Afebrile 

PR : 92 

BP : 130/80 mmhg 

RR : 22 

SPO2 : 88 % at RA 

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  

S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : 

 

INSPECTION:

shape of the chest : elliptical

No drooping of shoulders

Supraclavicular hollowness

No visible pulsation or scars

No crowding of ribs

PALPATION:

inspection findings are confirmed

Trachea central in postition

Apexbeat is normal in position

Restriction of movement on left side of chest

No tenderness

No local rise of temperature

Vocal fremitus diminished on left side

PERCUSSION dullness noted inframammary area

AUSCULTATION 

Normal vesicular breath sounds heard 

No additional sounds heard 

Vocal resonance increased

ABDOMEN EXAMINATION:

Shape of abdomen: scaphoid

 

Soft

No tenderness 

No palpable mass

Liver not palpable

CNS EXAMINATION 

Conscious ,alert

No motor deficit

No neck stiffness 

No signs of meningeal irritation 

 

No focal deficits

FAMILY HISTORY: Not significant 

 

Repeat x-ray : 15/2/22

16/2/22

17/2/22

18/2/22

Pulmo refferal

BAL performed on 19/2/22

PROVISIONAL DIAGNOSIS: 

Diabetic ketosis ( resolved )  secondary to

 Irregular medication 

With Left Lower lobe consolidation 

With cholelithiasis 

With DM since 4 years 

With Alcohol dependence