28 Chikatla Laharisha

CHIKATLA LAHARISHA
ROLL NO.28 
3RD SEMESTER

A 27 yr old male presented to casuality with left sided chest pain since 10 days worsening since yesterday night 
 HOPI : 
 Pt was apparently asymptomatic 15 days then he developed fever after spraying pesticides in field ,associated with cough with expectoration 
Pt was taken to a local doctor and treated symptomatically , but symptoms not relieved 
Pt developed left sided chest pain 10 days back ,non radiating ,diffuse pain ,pain increased on inspiration 
 Not a/w sweating, palpitations
pt was refered to our hospital in view of persistent fever ,cough with chest pain 

PAST HISTORY : 
 No h/o HTN,epilepsy,TB,asthma 

PERSONAL HISTORY :
 Appetite -normal 
Diet mixed 
Bowel and bladder- regular 
Sleep adequate 
Addictions - occasionally takes alcohol 250 ml a week from 5 years
Has a habit of tobacco chewing from 5 years

FAMILY HISTORY 
Not significant 

GENERAL EXAMINATION 
O/E pt is c,c,c 
Moderately built
No pallor ,icterus, cyanosis, clubbing, lymphadenopathy ,edema of feet 
 
Vitals :
Temp : 100.6
Bp :110/70
PR: 111
Rr: 22
Spo2: 97
GRBS:373mg/dl
RS:
Inspection : shape of chest : normal 
⁃ Symmetry of chest : symmetrical 
     ⁃ No visible scars , no sinuses , no engorged veins 
⁃ No deformities of spine 
⁃ No visible apical impulse 
Palpation:
        -No tenderness and no local rise of temperature 
⁃ Inspectory findings are confirmed
⁃ Trachea central 
⁃ Apex beat : felt at 5 th Intercoastal space medial to mid clavicular line
      - vocal fremitus 
Percussion :
Auscultation:
        -B/L Air entry pesent 
         -Left side inspiratory crepts in IMA,IAA 
       - Aegophony 

Cvs : s1 s2 heard ,no murmurs 
CNS: NAD 
PA : soft , non tender ,no organomegaly
  

Hemogram:
Haemoglobin:13.7
TC:24,500
RBC COUNT:4.8 million/cumm
PLATELET COUNT:4.5lakhs/cu.mm

COMPLETE URINE EXAMINATION:
Color:pale yellow
Appearance:clear
Albumin:++
Sugar:++
Pus cells:4-5
Epithelial cells:3-4

URINE FOR KETONE BODIES:+ve
 
ABG:
PH:7.29
PCO2:16.2
PO2:74.5
Hco3-:7.6
O2 sat:93.8 

RENAL FUNCTION TESTS:
serum creatinine:0.7
Serum urea:33
Ca+:10.0
Na+:132
K+:5.2
Cl-:9.4
PHOSPHATE:3.3

LIVER FUNCTION TESTS:
TB:0.66
DB:0.21
AST:19
ALT:10
ALP:150
Tp:5.1
Alb:2.7
  
PROVISIONAL Diagnosis : DIABETIC KETOACIDOSIS WITH 
                       ? LEFT MIDDLE LOBE PNEUMONIA 
                     WITH DENOVO TYPE 1 DM 

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