Hall ticket number 1701006131; N.JOSHUA PAUL, long case.

June 12, 2023

50/M FEVER COUGH WITH SPUTUM,UNCONTROLLED SUGARS

12/6/23

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CHIEF COMPLAINTS

The Patient came to hospital with the chief complaint of cough since

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

HOPI

Fever since 12-days high grade-not associated with chills and rigor, evening rise is seen 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 releiving 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 left femur with dynamic hip screw surgery done in another Hospital.Immobilisation 1-1/2 year back

H/o -electrocution

4-years back - Burns on 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, freshens up, takes his diabetic tab glimiperide, drinks tea at 7 am, eats breakfast (Rice) at 9am and due to his past RTA from 2yr back, had fracture near lateral part of upper thigh placement of rod implant was done. Since then he is not going to farming and stays at home.At 1:00 pm he takes lunch(Rice) and walks a few steps in house then sleeps for an hour. Eats dinner(Rice) at 9:00 pm and goes to sleep by 10:00pm.

PERSONAL HISTORY

Patient is an Alcoholic and Smoked 18 cigarettes a day. later he started smoking Beedi 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.

Diet is mixed

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.
Slight pallor is seen,
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:
Bp- 90/80mm Hg
Pr-90 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- 112mg/do