50/M FEVER COUGH WITH SPUTUM,UNCONTROLLED SUGARS

June 07, 2023

Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read!

CHIEF COMPLAINTS

Patient came with chief complaint of cough since

7 Days, Fever since 7 days, with difficulty in breathing since 7 days

HOPI

Fever since 15-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

K/C/O: Dm+ since 2years

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

H/o -electrocution

4-years back - Burns both hands

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy

No H/O similar complaints in the past

No past H/O TB, loss of appetite, loss of weight

DAILY ROUTINE

Patient wakes up at 5:30 am then gets freshened up, takes his diabetic tab and drinks tea at 7 am eats breakfast (Rice) at 9am and due to his past RTA 2yr back and had fracture near lateral part of upper thigh placement rod implant was done surgery since then he is not going to farming and stays in home. at 1:00 pm he takes lunch(Rice) and walks to surroundings few steps in house then sleeps for 1 hours then eats dinner(Rice) at 9:00 pm and goes to sleep by 10:00pm.

PERSONAL HISTORY

Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day.

Patient attendant said that their neighbour has TB ( who is son in law of him )

And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day

Patient started to have fever since 10 days at night time with burning sensation all over the body

Patient started to have unbearable pain at lower back during cough .and always needed help from attendants to hold his back during coughing.

PAST HISTORY

K/c/o DM since 2 years was diagnosed during his RTA treatment and is on regular Glimipride 1mg &Metformin 500mg medication since then.

He has no history of hypertension, diabetes ,asthma, epilepsy, tuberculosis.

GENERAL EXAMINATION

Patient is conscious, cooperative ,coherent and oriented with time , place , date.
Slightly pallor,
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:
Bp-80/40 mm Hg
Pr-102 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH