49 year old male with cough

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CHIEF COMPLAINTS:

49 year old male patient came to OPD with

Generalized weakness since 2 months cough since 20 days

HOPI:

Patient was apparently asymptomatic 20 days back then he developed cough with expectoriation mucoid in nature(light brown in colour) went to local hospital but not subsided with the treatment and presented to us with cough which is gradually progressing in nature,

Mucopurulent,foulsmelling,non blood stained more in the night

Halitosis - present

Associated with chest tightness

Associated with loss of appetite

Associated with loss of weight from 59 to 40 kgs in 6 months

No history of fever,chestpain,sob,sweating,palpitations

And decreased urineoutput

PAST HISTORY:

No similar complaints in the past

There is history of diabetes mellitus

No h/o hypertension,asthma,tb,epilepsy,thyroid disorders

PERSONAL HISTORY:

Diet: mixed

Appetite:decreased

Bowel and bladder: normal

Sleep: disturbed since 20 days

Addiction:since 25 yrs he is chewing tobacco

Since 20 yrs he is taking alcohol

Both stopped 2 months back

ALLERGIC HISTORY:

Absent

DRUG HISTORY:

Absent

FAMILY HISTORY:

not relevant

GENERAL PHYSICAL EXAMINATION:

Consent is taken 

Patient is conscious,coherent ,cooperative,well oriented to time ,place,person moderately built and moderately nourished

Temp: afebrile

Pulse rate: 86 BPM

RR:20 cycles/ min

BP:120/80 mmHg

No pallor,icterus,cyanosis,lymphadenopathy,

Edema

LOCAL EXAMINATION:

Respiratory system:

Inspection:

Upper respiratory tract:no dns,polyps,turbinate hypertrophy,

Oral cavity: dental stains present

Posterior pharyngeal wall : normal

Lower respiratory tract:

Shape of the chest: symmetrical, and elliptical

Chest expansion equal on both sides

Position of trachea - central

A large hypopigmented patch seen over anterior chestwall

no sinuses ,scars,engorged veins and visible pulsations

PALPATION:

All inspectory findings are confirmed

No local rise of temperature 

Trachea is central in position

Anteroposterior diameter:28cm

Transverse diameter:24cm

Percussion:resonant (equal in all areas)

Auscultation:

Bilateral air entry present

Non vesicular breath sounds

No added sounds

Vocal resonance:increased in interscapular area

CVS:

S1,S2 present

PERABDOMEN:

soft and nontender

CNS:

no focal neurological deficit

PROVISIOANL DIAGNOSIS:Right upper lobe cavitatory lesion(aspergilloma?) with diabetes mellitus type 2

INVESTIGATIONS:

2/1/23

Chest x ray

04/1/23

HEMOGRAM:

Hemoglobin 16.4gm/dl

neutrophils 83%

lymphocytes 10%

eosinophils 01%

monocytes 06%

basophils 00%

PCV 46.2vol%

MCV 85.1 fl

MCH 30.2 pg

MCHC 35.5%

RDW CV 10.7 %

RDW SD 34.3 fl

RBC COUNT 5.43 million/cumm

platelet count:3.18lakhs/cumm

URINE FOR KETONE BODIES:

positive

URIC ACID SERUM:

3.1 mg% (normal value:3.5 -7.2)

SERUM SODIUM :

130mmol/L

SERUM POTASSIUM:

4.1mmol/L

SERUM CHLORIDE:

97mmol/L

SERUM CREATININE:

0.8mg/dl

POST LUNCH BLOOD SUGAR:

480mg/dl

LIVER FUNCTION TESTS:

TOTAL BILIRUBIN 1.26mg/dl

 DIRECT BILIRUBIN:0.35mg/dl

SGOT:11 IU/L

SGPT: 17 IU/L

ALKALINE PHOSPHATASE 233IU/L ( NORMAL 53 -128)

TOTAL PROTEINS: 7.3G/DL

ALBUMIN : 3.41 g/dl (normal 3.5 -5.2)

A/G RATIO 0.88

BLOOD UREA :33mg/dl

5/1/23

Anti HCV Ab : non reactive

HBS Ag : negative

C REACTIVE PROTEIN: 2.4mg/dl

TREATMENT:

Inj. Piptaz 4.5 mg IV TID

Inj. Metrogyl 500 mg TID

Inj. PAN 40 mg BBF

Syp. Aptivate 10ml/BD

NS IV 500 ml@ 100ml/hour

Inj. HAI according to GRBS

Inj. Thiamine 100 mg/ IV/BD