1702102017 LONG CASE

A 34 year old male,resident of tangapally, nalgonda ,farmer by occupation  presented to casuality with

C/o fever since 3 days associated with chills.
cough with expectoration yellowish in colour Since 3 days 
Shortness of breath since 3days

History of present illness : 
Patient was apparently asymptomatic 6 months back he had history of chest pain - left sided for 2 days which subsided on medication (? Unknown )

Pt Stopped consuming alcohol for 1 month 
History of fall from bike under influence of alcohol sustained injury to right clavicle  and therefore had to stop going to work for 1 month .currently pt complains of History of  high grade ,continuous type of fever since 3 days  ,subsided on taking medication and on the next day fever was associated with chills and cough with expectoration - yellowish in color ,mucoid in constistency ,cold present (now subsided)History of sob present ,grade 2 - 3 ( which made him come the hospital )  since 2 months which got aggravated from 4 days,not associated with orthopnea,paraoxysmal nocturnal dyspnea,not associated with palpitations,excessive sweatings,giddiness.

No history of pedal edema,burning micturition ,decreased urine output,pain abdomen

Past history : 
Not a K/C/O DM,HTN,Asthma ,TB,epilepsy 
No similar complaints in the past 
No history of any surgeries or blood transfusions 

Personal history : 
Married 
Diet - mixed 
Appetite - decreased 
Sleep - adequate 
Bowel and bladder movements : regular 
Alcohol consumption - daily 90 ml whiskey since 10 years 
No history of smoking 

O/E:
Pt is conscious,coherent and cooperative
Moderately built and nourished.
No signs of pallor,icterus , clubbing, cyanosis lymphadenopathy,edema 

Vitals: 
Afebrile to touch
BP: 140/70
PR: 116 bpm
RR: 28 cpm
Spo2: 95% on room air
General examination:-

Systemic examination:

CVS: S1,S2 heard 

RS: vesicular breath sounds,left side inspiratory crepts in infrascapular area ,infra axillary area 
Right side - decreased breath sounds in infrascapular area and infraaxiallary area

 CNS: no focal neurological deficit

Per abdomen: soft ,non tender,bowel sounds+

Provisional diagnosis : bilateral LL consolidation with pleural effusion ?CAP ?Viral pneumonia ?wet beri beri

 Investigations :

 HEMOGRAM : 
Hb - 11.7 
TLC - 8900 
N - 70 
L - 21 
M - 07
E - 02 
Pcv - 34.2 
MCV - 80.7 
MCH - 27.6 
MCHC - 34.2 
RBC - 4.24 
Plt - 2.54 RFT : 
Creatinine - 0.8 
Urea - 13 
Na - 139 
K - 4 
Cl - 97 

LFT : 
TB - 1.03 
Db - 0.23 
AST - 15
ALT - 23 
ALP - 172
TP - 5.2
ALB - 3.3 
A/G - 1.74
ECG:-

Chest x ray :-

USG abdomen :
2d echo


Treatment plan:

1) IVF - NS and RL with optineuron  @100 ml/hr 
2) TAB .PCM 500 mg PO TID  
3) INJ.AUGMENTIN 1.25 GM/IV /BD 
4)TAB.AZITHRAL 500 MG PO/OD 
5) NEB with mucomist ,budecort @12th HRLY and asthalin @ 8th HRLY 
6)INJ.PAN 40 mg IV/OD
7)INJ.THIAMINE 1 amp in 100 ml /SYP.BENADRYL P 10 ml/PO/TID 

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