camp case 14/5/24

Camp case
A 42yr old male came with

CHEIF COMPLAINTS:
Came with c/o fever since 1 month
            c/o cough since 1 month

HOPI:
Pt was apparently asymptomatic 1 month back and then he developed fever, insidious onset, high grade, continuous with chills and rigors, relieved with medication. 
Cough with expectoration since 1 month, with yellowish sputum, non blood stained, non foul smelling.
H/o weight loss since 2 months 
PAST HISTORY:
K/c/o T2 DM since 5years and on medication. (Tab.METFORMIN 500mg
Tab.GLIMIPERIDE 1mg once daily
H/o seizure episode 2yrs back, with involuntary movements of both up
N/k/c/o HTN/TB/Asthma

No other comorbidities 

PERSONAL HISTORY:
Married
Diet: mixed
Appetite: normal
Sleep: adequate 
Bowel movements: regular
Bladder habits: regular 
Addictions: alcoholic 
  Smoker since 15yrs
Allergies:no

GENERAL EXAMINATION 
O/e 
Pt c/c/c 
Temp - afebrile 
Pr - 62bpm
Bp -110/70 mmHg 
No pallor
No icterus
No cyanosis
No clubbing
No pedal odema 
No lymphadenopathy

SYSTEMIC EXAMINATION:

Cvs -S1,S2 heard 
Rs - Bae +nt,nvbs 
P/a - soft ,nt 
CNS - tone -normal 
Power 5/5 in all limbs 
Reflexes - 
B. +2, +2
T. +2.  +2 
S- +1   +1
K. +2 +2
A. +1.  +1
P - F F 

Senosory system 
Fine touch - intact 
Crude touch - intact 
Vibration sense - intact


Investigations 

TREATMENT GIVEN:
14/5/24
1)NEB with IPRAVENT 6th hourly and BUDECORT 12th hourly
2)Syp.GRILINCTUS 15ml PO/TID
3)TAB PCM 650mg
4)GL1M1-M1 PO/0D
5)MONITOR VITALS AND INFORM SOS
6)INJ. AUGMENTIN 1.2gm i.v TID
7)INJ. PCM 3amp in 100ml NS i.v/ SOS
8)Temp. Monitoring 4th hourly

15/5/24
1)NEB with IPRAVENT 6th hourly and BUDECORT 12th hourly
2)INJ.PAN 40mg i.v OD
3)Syp.GRILINCTUS 15ml PO/TID
4)TAB PCM 650mg PO TID

6)MONITOR VITALS AND INFORM SOS
7)INJ. AUGMENTIN 1.2gm i.v TID
8)INJ. PCM 3amp in 100ml NS i.v/ SOS
9)I.V FLUID NS @50ml/hr
10)INJ. HUMAN ACTRAPID INSULIN S/C TID according to GRBS

PROVISIONAL DIAGNOSIS:
? COMMUNITY ACQUIRED PNEUMONIA RT UPPER LOBE AND MIDDLE LOBE CONSOLIDATION , 2° TO TB 


































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