A 50 y/o male with fever and cough

 

A 50 y/o male with fever and cough

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Chief Complaints

A 50 y/o male , from Chityala, presented with chief complaints of fever, cough and weakness since 4 days ago.

History of Presenting Illness

Patient was apparently asymptomatic 4 days ago and then he developed a fever along with cough. He also became increasingly lethargic, unable to walk around his home. He visited a local PHC 2 days ago and took the medication prescribed there. There was no improvement observed. 

The fever starts in the evenings and is accompanied by chills and sweating that increases in the night time.

The cough is dry and is aggravated when he attempts to eat.

He is unable to eat food in the evenings, and after intake of food, he has had an episode of vomiting- non bilious, with food particles and non projectile.

PAST HISTORY

The Patient is a known case of diabetes since 3 years ago- diagnosed and treated by oral medication at a PHC.

The patient suffers from severe pain in the lumbar region and pain in the knee joints, since 3 years ago, he has not received any treatment for his pain other than herbal medicine/ balms.

No history of hypertension, asthma, TB, CVD,CKD

Personal History

Diet- Mixed

Appetite- Reduced

Bowels- regular

Bladder- Increased frequency of urination

Sleep- disturbed 

Addictions- used to consume alcohol regularly, stopped 10 years ago.

Family History

No significant Family History

General Examination

Patient is conscious , coherent and cooperative.

He is well oriented to time, place and person

He is moderately built and nourished

Patient is afebrile

Pallor: present

Icterus: absent

Cyanosis: absent

Koilonychia: absent

Pedal edema: absent

Lymphadenopathy: absent

VITALS 

Temperature: afebrile

Respiratory rate: 32/min

Blood pressure: 110/80 mm Hg

Pulse: 110 bpm, rate, rhythm , volume, character normal, no radio-radial / radio-femoral delay

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

Inspection:

Chest is symmetrical in shape,

 no dilated veins, scars, nodules or sinuses present.

JVP is not raised

Palpation:

Trachea: midline

No intercostal tenderness

Percussion:

Dullness on left side.

Right side normal- resonant

Auscultation:

Normal Vesicular Breath sounds heard

No added sounds

CVS:

S1, S2 heard

No murmurs

GIT:

Abdomen: soft,  non tender, no organomegaly, umbilicus is not everted.

CNS examination:

Patient is conscious.

No weakness in the upper limbs,

No paraesthesias

No sensory disturbances in the lower limb

Lower limb tone, power is normal