A 48 years old male toddy tree climber by occupation since past 30 years.The Patient came with C/o chest pain since one day.C/o fever, cold and cough since 3 - 4 days.

48 years old male  toddy  tree climber by occupation since past 30 years,
Pt came with C/o chest pain since one day.
C/o fever, cold and cough since 3 - 4 days. 

HOPI : 
Pt was apparently asymptomatic 4 days back then developed fever - high grade associated with chills and rigor , on and off , relieves with medication.
C/o dry cough , aggrevates at night 
C/o SOB due to excessive coughing,  orthopnea  - , PND - 
C/o 1 episode of vomiting associated with food particles 1 day back - non bilious
Pt had similar complaints of fever associated chills and rigor in the past since 5 years
4 years back pt got hospitalized with fever and chills and got diagnosed with DM , on OHA ( met formin hydrogenchloride po/od ) - irregular medication.
In past 5 years , pt had 5 - 6 hospital admissions with similar complaints due to heavy drinking  and got diagnosed with fatty liver and jaundice.
H/o seizures  since 5 years 
4 - 5 episodes in last 5 years , with gap of 1 year in between the episodes .
Last episode -  1 year back 
Tongue bite + , Remains in unconscious state for 5 mins
H/o multiple RTA s with minor injuries over left hand, left knee, right eye, right ankle
H/o covid +  1 year back 
Received 1 dose of vaccine - covishield 

PAST HISTORY: 
Not a /K/C/O  HTN, TB , CAD, ASTHMA 
No c/o abdominal pain , nausea , burning micturition 

PERSONAL HISTORY : Appetite - normal
Bowel movements - Regular 

Chronic alcoholic since past 30 years 
Heavy drinking since past 10 years ( 360 - 480 ml/day )
Pt went to rehabilitation for 1 year ,but never stopped drinking, as told by patient attenders 

O/E : Patient is C/C/C 

Pallor - absent

Icterus  - present

Cyanosis - absent

Edema of feet - absent

Lymphadenopathy  - absent

Clubbing - absent


VITALS :  

Temp :  Afebrile 

PR : 92 

BP : 120/80 mmhg 

RR : 22 

SPO2 : 88 % at RA 


SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  

S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : 

Bilateral air entry present ,  reduced breath sounds in left IAA , IMA, ISA , on auscultation  wheeze - present

CNS : NAD 

PA :  soft, non tender 

FAMILY HISTORY: Not significant 








INVESTIGATIONS : 


























Repeat x ray  15/2/22 : 


Psychiatry referral done on 15/2/22 :








PROVISIONAL DIAGNOSIS: 
Diabetic ketosis   secondary to  sepsis 
Irregular medication 
With  Left Lower lobe consolidation 
With cholelithiasis 
With DM since 4 years 

TREATMENT: 

1. Inj PAN 80 mg/iv/stat
2. Inj. Zofer 4 mg/iv/stat
3. Inj. HAI 1 ml in 39 ml NS iv/according to grbs
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine  in 100 ml NS/iv/tid
9. Inj. Optineuron 1 amp in 100 ml NS/iv/od
10. IVF NS, RL @ 100 ml/hr
11 Hourly GRBS charting.

Day 2

S :  Chest pain reduced 
      1 episode of fever spike 
       C/o  cough 
      On examination :
No pallor/cyanosis/generalized lymphadenopathy
Temp : 100.1
PR : 101 bpm
RR : 19 cpm
BP : 160/90 mmhg
Spo2 : 87 % at RA
CVS : S1 S2 + , No murmurs 
RS : BAE + , Reduced breath sounds in left lower lobe
PA :  Soft, non tender  
GRBS :
8 AM :  263 mg/dl
10 AM :  154 mg/dl
2  PM :  189 mg/dl
4  PM :  194 mg/dl
8  PM :  187 mg/dl
10 PM :  179 mg/dl
2  AM :  155 mg/dl
8  AM :   178 mg/dl                      

A : 
Diabetic ketosis   secondary to ? sepsis 
? Irregular medication 
With ? Left Lower lobe consolidation 
With cholelithiasis 
With DM since 4 years 

P : 
1. Inj PAN 80 mg/iv/stat
2. Inj. Zofer 4 mg/iv/stat
3. Inj. HAI 1 ml in 39 ml NS iv/according to grbs
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine  in 100 ml NS/iv/tid
9. Inj. Optineuron 1 amp in 100 ml NS/iv/od
10. IVF NS, RL @ 100 ml/hr
11 Hourly GRBS charting.

DAY 3

S :  Pain reduced by 70% since admission
      No fever spike 
      Cough reduced 
      
On examination :
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6
PR : 80 bpm
RR : 21 cpm
BP : 110/70 mmhg
Spo2 : 90 % at RA
CVS : S1 S2 + , No murmurs 
RS : BAE + 
PA :  Soft, non tender  
GRBS :
8 PM :  161 mg/dl  
8  AM :  195 mg/dl                 

A : 
Diabetic ketosis   secondary to ? sepsis 
? Irregular medication 
With ? Left Lower lobe consolidation 
With cholelithiasis 
With GB sludge
With DM since 4 years
With Alcohol dependence 

P : 
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3.              8 am       2 pm       8pm
  Inj. HAI     6 U           -             6 U
        NPH    6 U           6 U        6  U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine  in 100 ml NS/iv/tid
9. Syp. Benadryl  5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs

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