56/M with fever and Sob since 4 days

 

A 56/M Came with complaints of 

Fever since 4 days

Sob since 4 days

pain abdomen since 4 days

burning micturition since 4 days


H/O PRESENT ILLNESS


Patient was apparently asymptomatic 1 year ago and then he had cough & SOB for which he got tested and diagnosed with TB

used ATT for 3 months and stopped

From then he was asymptomatic until 10 days back when he developed cough & generalized weakness for which he used some medication (unknown) from a local practitioner

And since 4 days he developed fever , SOB , pain abdomen and burning micturition.

No history of pedal edema/decreased urine output

No h/o vomiting/loose stools

No other complaints 


PAST HISTORY 

De Novo detected Diabetes Mellitus ( 4 days ago)

H/o pulmonary tuberculosis 1 year ago ( used medication for 3 months and discontinued)

Not a K/C/O HTN/ asthma / Ischemic heart disease 


FAMILY HISTORY :

NO SIGNIFICANT FAMILY HISTORY


PERSONAL HISTORY:

OCCUPATION FARMER

DIET MIXED

APPETITE NORMAL

SLEEP NORMAL

BOWEL AND BLADDER HABITS NORMAL

ADDICTIONS: ALCOHOLIC ( occasional drinker)

SMOKING + 5/ day 



GENERAL EXAMINATION :

Patient is concious coherent and coperative


VITALS :

BP 130/90mmofHg

PR 112 bpm

TEMP 102 degrees F

SPO2 98 @ RA

GRBS 173mg/dl.



NO PALLOR, ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY 


SYSTEMIC EXAMINATION:


CVS-S1 S2+


P/A-SOFT, NON TENDER, NO ORGANOMEGALY


RS-Barrel shaped chest +

       BAE +

       















Provisional diagnosis:

Right lower lobe synpneumonic effusion ?CAP

?PTB reactivation

Sepsis with AKI on ?CKD

Denovo DM
















  



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 1.  https://drkeerthimadireddy.blogspot.com/2023/04/57m-mdr-tuberculosis.html 2.  https://drkeerthimadireddy.blogspot.com/2023/04/67m-ptb-with-uncontrolled-type-2-dm-htn.html 3.  https://drkeerthimadireddy.blogspot.com/2023/04/80m-ptb-cap-aki-rhf-htn.html 4.  https://drkeerthimadireddy.blogspot.com/2023/04/67m-ptb-chronic-pancreatitis.html 5.  https://drkeerthimadireddy.blogspot.com/2023/04/20m-ankle-tb.html 6.  https://drkeerthimadireddy.blogspot.com/2023/04/64m-tb-meningitis-aki.html 7.  https://drkeerthimadireddy.blogspot.com/2023/04/65m-tuberculosis.html 8.  https://drkeerthimadireddy.blogspot.com/2023/11/48f.html 9.  https://drkeerthimadireddy.blogspot.com/2024/01/49-m-ptb-denovo-dm.html 10.  https://drkeerthimadireddy.blogspot.com/2023/04/60f-ptb-dm2-cad.html 11.  https://drkeerthimadireddy.blogspot.com/2023/04/50m-ptb.html 12.  https://drkeerthimadireddy.blogspot.com/2023/07/55m-malnutrition-ascitis-tb-peritonitis.html 13.  https://drkeerthimadireddy.blogspot.com/2023/07/60m-so
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