45 year old male patient with cough and fever

 A 45 year old male resident of mallapuram and farmer by occupation presents with chief complaints of fever  since 1 week and cough  since 3 days.

HOPI: The patient was apparently asymptomatic 1 week ago .Then he developed fever which was sudden in onset ,gradually progressive and not associated with chills and rigor. He complained of nocturnal rise of temperature. He developed cough which was productive and blood tinged occasionally. He also complaints of burning sensation in the feet.

No history of nausea and vomiting 

No history of weight loss

No history of burning micturition


Past History : 3 years ago he met with electric shock .And 1 year ago he met with a RTA following which an implant was placed in his left hip .

He is a K/C/O Diabetes since 2 years 

No history of asthama ,hypertension ,epilepsy and blood transfusions .


Personal History : 

Appetite: Normal 

Diet : Mixed 

Sleep : Adequate 

Bowel and Bladder : Normal 

Addictions : 

He has been drinking  3 -4 units  of whisky on a daily  basis since last 15 years 

He has been smoking cigar on  a daily basis since 15 years 

No history of any allergies .

 

General Examination 

Examination was done after taking the consent of the patient in a well ventilated room.

Patient is conscious, coherent 

Moderately built ,nourished

Well oriented to time  place and person .

No Pallor 

No icterus

No cyanosis 

No clubbing of fingers 

No pedal oedema 

No lymphadenopathy 


Vitals : 

Temperature  : Febrile 

Pulse : 100bpm Normal volume and normal rhythm 

BP : 110/ 70 mmhg

Respiratory Rate: 20 cpm


Respiratory System Examination 

Inspection : 

Chest is symmetrical 

Trachea is midline 

No scars or dilated veins 


Palpation : 

Trachea is in midline 

Apex beat present 

Vocal fremitus is present 

Chest expansion is symmetrical 

Percussion : Not elicited 

Auscultation :

Bronchial sounds are heard and are normal 

Vesicular sounds are normal with crepitus in the left supra mammary region 


CVS Examination :

S1 and S2 heard with no murmurs 


Abdominal Examination :

Abdomen is scaphoid in shape ,non Distended 

Soft and non tender 

Bowel sounds are present 


CNS Examination : 

Higher mental functions 

Conscious and coherent 

Well oriented to place time and person 

Speech is normal 

No dementia 

No signs of meningeal irritation 


Cranial nerves : 

All 12 Cranial nerves are intact 


Sensory system and motor system are normal .


Provisional diagnosis: 

Military TB 

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