44M PTB DM

 Case History and Clinical Findings : 

PATIENT CAME TO OPD WITH COMPLAINTS OF COUGH SINCE MONTHS, LOSS OF APPETITE SINCE 2 MONTHS , FEVER SINCE 1 AND HALF MONTHS 


HISTORY OF PRESENT ILLNESS : PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO, THEN HE DEVELOPED COUGH WHICH IS PRODUCTIVE (THICK, WHITISH SPUTUM) NON BLOOD TINGED, NON MUCO-PURULENT , NO DIURNAL VARIATION


CO FEVER WHICH IS HIGH GRADE, INTERMITTENT, RELIEVED WITH MEDICATION ASSOCIATED WTH CHILLS AND RIGOR WITH NO DIURNAL MARIATION.

CO LOSS OF APPETITE SINCE 2 MONTHS.

NO C/O BURNING MICTURITION, COLD, HEADACHE, BODY PAINS.

NO C/O CHEST PAIN, PALPITATIONS, SOB.



PAST HISTORY

K/CO TYPE 2 DM SINCE 8YRS (ON TAB SITAGLIPTIN 500MG + METFORMIN 1000MG PO/OD) 

NOT AK/C/O HTN, CAD, CVA.



GENERAL EXAMINATION:

THE PATIENT IS CONSIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME, PLACE AND PERSON, MODERATELY BUILT AND NOURISHED.


VITALS

BP: 110/70 MMHG

PR: 88 BPM RR: 18 CPM

TEMP, 984 F

CVS: S1, S2 HEARD, NO MURMURS 

RS: BAE +, NVBS, NO ADDED SOUNDS 

PIA. SOFT, NON TENDER l

CNS : NFND



Investigation

18/8/23

RBS - 275 MG/DL CUE!

ALBUMIN - TRACE

SUGAR - NIL

PUS CELLS 2-3


18/8/23

RBS - 275 MG/DL

CUE

ALBUMIN- TRACE

SUGAR - NIL

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

HEMOGRAM :

HB - 13.5 GM/DL

TLP- 12,500 CELLS/CUMM

PCV - 39.6 VOL%

PLATELET - 2.06 LAKHS/CUMM


RFT

UREA: 21 MG/DL

CREATININE: 1.1 MG/DL

URIC ACID: 3.0 MG/DL

CALCIUM: 9.6 MG/DL

PHOSPHOROUS: 3.5MG/DL


SODIUM: 132 MEQL

POTASSIUM 3.8 MEQL

CHLORIDE 96MEQL


LFT 

TB 1.15 

DB 0.63 


ALBUMIN 3.58











Sputum AFB positive, sputum CBNAAT positive.

PATIENT WAS STARTED ON ATT 4 TABS/ DAY AND ON FOLLOW UP HE WAS DOING WELL.


OUTCOME - COMPLETELY RECOVERED



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