A 50 y/o male with fever and cough

 This is an online E- log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


CONSENT AND DEIDENTIFICATION : The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.


Chief Complaints

A 50 y/o male , from Chityala, presented with chief complaints of fever, cough and weakness since 4 days ago.


History of Presenting Illness

Patient was apparently asymptomatic 4 days ago and then he developed a fever along with cough. He also became increasingly lethargic, unable to walk around his home. He visited a local PHC 2 days ago and took the medication prescribed there. There was no improvement observed. 

The fever starts in the evenings and is accompanied by chills and sweating that increases in the night time.

The cough is dry and is aggravated when he attempts to eat.

He is unable to eat food in the evenings, and after intake of food, he has had an episode of vomiting- non bilious, with food particles and non projectile.

PAST HISTORY

The Patient is a known case of diabetes since 3 years ago- diagnosed and treated by oral medication at a PHC.

The patient suffers from severe pain in the lumbar region and pain in the knee joints, since 3 years ago, he has not received any treatment for his pain other than herbal medicine/ balms.

No history of hypertension, asthma, TB, CVD,CKD

Personal History

Diet- Mixed
Appetite- Reduced
Bowels- regular
Bladder- Increased frequency of urination
Sleep- disturbed 
Addictions- used to consume alcohol regularly, stopped 10 years ago.

Family History
No significant Family History

General Examination
Patient is conscious , coherent and cooperative.
He is well oriented to time, place and person
He is moderately built and nourished
Patient is afebrile

Pallor: present



Icterus: absent
Cyanosis: absent

Clubbing: absent


Koilonychia: absent
Pedal edema: absent
Lymphadenopathy: absent

VITALS 
Temperature: afebrile
Respiratory rate: 32/min
Blood pressure: 110/80 mm Hg
Pulse: 110 bpm, rate, rhythm , volume, character normal, no radio-radial / radio-femoral delay

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:
Inspection:
Chest is symmetrical in shape,
 no dilated veins, scars, nodules or sinuses present.
JVP is not raised

Palpation:
Trachea: midline
No intercostal tenderness

Percussion:
Dullness on left side.
Right side normal- resonant


Auscultation:
Normal Vesicular Breath sounds heard
No added sounds



CVS:
S1, S2 heard
No murmurs

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




CNS examination:
Patient is conscious.
No weakness in the upper limbs,
No paraesthesias
No sensory disturbances in the lower limb
Lower limb tone, power is normal



Investigations:
Blood Sugar- Fasting


Blood sugar- Post lunch



Haemogram
ESR

CUE



Creatinine


Potassium
2D ECHO













USG









Provisional Diagnosis:

- lobar pneumonia 

-TB(?)





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