Fever and productive cough

 32yr old male with fever since 10days and productive cough since 5days

August 03,2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


32 year old male who is a village revenue assistant by occupation came to opd with c/o 

Fever since 10 days

Productive cough since 5 days


HOPI:

Patient was apparently asymptomatic 10 days ago then he developed fever which is low grade , intermittent type, Mainly during night time and relived temporarily with medication , associated with chills and rigors.

C/o productive cough with mucoid sputum, intermittent type, which is mainly during night time.

-Generalised weakness present

-Not associated with burning micturition ,cold,rash ,body pains ,vomitings,loose stools

-Associated with sob on doing ordinary activity( grade 2 mmrc) since 5 days , relieves on taking rest


Past history:

Not a k/c/o DM,HTN ,CVA,CAD ,ASTHMA

Patient had a trauma history 5 years back his leg was injured totally, bandage applied for it

He is know case of HIV (diagnosed 1 year ago )and he is on medication


Personal history :

Diet-mixed

Appetite-normal

Sleep-adequate

B and bladder movements-normal

Addictions-toddy -12 years back ,occasionally



Daily routine -

The patient is a village revenue assistant by occupation.He wakes up by 7 am freshens up and takes his breakfast at 8:00am and goes to his work,Then he takes lunch break at 1pm and goes back to work ,he takes dinner by 8 pm and sits with his children for some time the goes to sleep at 9pm.

His daily activities are disturbed. Due to his symptoms


GENERAL EXAMINATION:

-No palor

-No Icterus

-No cyanosis 

-No lymphadenopathy

-No edema

-No clubbing of fingers




Temperature:

 Febrile - 99.9°F

Pulse: 82 beats per minute

Respiratory rate: —16 cycles per minute

Blood pressure: 130/90 mm of Hg


SYSTEMIC EXAMINATION:


Cardiovascular system:

No thrills

No murumurs

Cardiac sounds: S1, S2 present 


Respiratory system:

Bilateral airway entry present ,crepts heard in IAA ,left ISA ,Right IAA


Abdomen: 

shape scaphoid 

umbilicus central , inverted

no increase in local temp,no tenderness

No spleenomegaly

No hepatomegaly

BS+


Investigations:



Diagnosis:

Pyrexia under evaluation

?pulmonary Tb

? community acquired pneumonia


03/08, 1:15 pm

Date of admission:2/08/23


Ward patient

Dr.Rakesh Biswas(HOD)

Dr.Zain Alam(SR)

Dr.Narsimha Reddy(PGY2)

Dr.Lohith Varma(PGY1)





S : c/o High grade fever since 10 days

Productive cough since 5 days





O:  


Patient is conscious coherent and cooperative  

No pallor, icterus , clubbing, cyanosis, lymphadenopathy, 


Vitals :   


BP- 140/100mmHg 

PR -83bpm 

RR-18 cpm 

Temperature - 101°c


Date of admission:2/08/23


Ward patient

Dr.Rakesh Biswas(HOD)

Dr.Zain Alam(SR)

Dr.Narsimha Reddy(PGY2)

Dr.Lohith Varma(PGY1)

S : c/o productive cough

And body pains

O:  


Patient is conscious coherent and cooperative  

No pallor, icterus , clubbing, cyanosis, lymphadenopathy, 


Vitals :   


BP- 120/80 mmHg 

PR -78 bpm 

RR-18 cpm 

Temperature - 99 F


CVS: s1,s2 heard, no Murmurs 

RS: BLAE+, crepts present in Right IAA 

P/A: soft, nontender, No organomegaly

CNS:NFND , NHMF

A: Pyrexia under evaluation ? Since 10 days ? CAP?pulm tb

K/c/o Retroviral disease since 1 year

P:

1)Inj Neomol 1 gm /iv/sos

2)Tab Azithromycin 500 mg /po/of /8am

3)Tab Dolo 650 mg/po/TID

4)syp Ascoryl -Ls po/TID

5)Tab Dolutegravir (50mg) + Lamivudine (300mg)+Tenofovir(300mg) po/Hs/9 pm



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