PNEUMONIA WITH DIABETIC KETOSIS
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40 year old male, labourer by occupation, low socioeconomic status from narketpalli came to opd with
Cheif complaints:
Breathlessness since 1month
Fever since 10 days
Chest pain since 4 days
History of present illness:
Patient was apparently asymptomatic 1 month back, then developed
Breathlessness which was insidious onset which used to be grade 2(MMRC) and progressed to grade 4 since last 4 days with no postural or diurnal variation associated with generalised weakness and followed by
Low grade fever on and off since 10 days not associated with chills and rigor, shows no diurnal variation and relieved on medication, and
Cough since 7 days, associated with moderate amount of purulent sputum mixed with saliva which is whitish in colour with no postural variation and
Chestpain on left side on inspiration and coughing since 4days which was non radiating and relieved on lying down.
No complaints of Palpitation, syncopal attack, , haemoptysis, recurrent sore throat, hoarseness, choking episode, joint pains, burning micturition,loose stools,constipation,Nausea,Vomiting.
Past history:
Not a Known case of DM, hypertension, epilepsy, asthma, CVD, TB, thyroid disease
Family history:
None of patients attenders have similar symptoms, or have asthma, TB, hypertension, or significant co morbidity.
Personal history:
Diet mixed
Appetite decreased
Sleep adequate
Chronic smoker since 14yrs 16-18 beedis/day
Chronic alcoholic since 10yrs and consumes 90ml/day.
Bladder and bowel movements are regular
General examination:
I took the informed consent of the patient before examining.
I have examined the patient in supine and sitting position.
Patient is conscious coherent cooperative well oriented to time place and person, has generalised wasting of muscles and is comfortable on bed.
There is no pallor, icterus, cyanosis koilonychias, clubbing, lymphadenopathy, pedal edema
JVP is not elevated, hepatojuglular reflex absent.
Vitals:
Temperature :Afebrile,98 F
Respiratory rate- 40 cycles per minute
Pulse rate 100 beats/min regular in rhythm character volume
Blood pressure 90/70 mmHg left arm in sitting position.
Spo2 98% on room air.
Systemic examination
Respiratory system:
1. Upper airway
Nose normal alae Nasi, septum
Oral cavity teeth pharynx normal no sinus tenderness
2. Examination of chest
INSPECTION
Shape of chest is elliptical
Both the shoulders appear to be at the same level
Trachea appears to be central
Apical impulse is not visible
Skin over chest is normal
Trail sign is absent
Hollownesss in supraclavicular and infra clavicular fossae
Movements of respiration:
Tachypnea is present and abdomino thoracic respiration
PALPATION
No local rise of temperature
No tenderness
Chest is expanding equally on both sides
Tactile vocal fremitus is increased infra axillary infra scapular areas both sides
No palpable thrills crepitation pleural rub
PERCUSSION
Direct percussion on clavicle, sternum and Manubrium is resonant
Kronig isthmus resonant both sides
Indirect percussion(left) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-6 intercostal spaces areas resonant, 5-7 intercostal spaces dull, posterity 9th intercostal space dull
Traube space is dull.
Indirect percussion(right) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-7 intercostal spaces are resonant. posterity 9th intercostal space resonant.
AUSCULTATION
Left side infra clavicular, mammary, supra scapular, normal vesicular breath sounds, decreased bronchial breath sounds at infra axillary, scapular, infra scapular areas.
Crepitations at infra scapular area
whispering pectoriloquy is present.(vocal resonance increased)
Right side infra clavicular, mammary, supra scapular, infra axillary, infra scapular areas-vesicular breath sounds
Other system examination
CNS - no facial asymmetry all reflexes are normal
CVS- S1 S2 heard no added murmurs
ABDOMEN - abdomen is scaphoid with no organomegaly
INVESTIGATIONS:
Chest xray:
Diagnosis:
This could be a case of left lower lobe pneumonia with diabetic ketosis
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