65 year old male with complaints of fever with chills

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

CASE

A 65 year old male farmer by occupation resident of nalgonda came to the opd with chief complaints of fever with chills since 5 days 

HOPI:

Patient was apparently asymptomatic 5days back then he developed fever which is continuous Subsided with medication,
No history of burning micturition, vomiting,loose stools

Patient was diagnosed with diabetes mellitus 5 years ago and started on oral hypoglycemic drugs 
4 years ago patient had shortness of breath and came to our hospital and was admitted,was told to have lung infection and mass and was started on insulin.
Since 4 years patient had skin lesions with scaling over legs and hands which progressed gradually used steroids and tapered.As the lesions kept progressing patient underwent skin biopsy 1 month ago which showed munro microabscess suggestive of psoriasis.He has been using medication for psoriasis since 1 month.
H/o unstable angina 1 and half year back-PTCA was done.

Past history:
K/c/o DM since 5 years
Not a k/c/o HTN,TB,Asthma, epilepsy, thyroid disorders.

Personal history:
Diet-mixed
Bowel and bladder movements-irregular
Appetite-decrease
Sleep-adequate
No addictions

Family history:
Not significant

General examination:
Patient is concious,coherent, cooperative.
No pallor,icterus,cyanosis, clubbing,lymphadenopathy,edema.

Vitals on admission:
Temperature-99 F
PR-64 bpm
RR-18 cpm
BP-80/60 mmHg 


Systemic examination:
Cardio vascular system-S1,S2 heard,No murmurs
Respiratory system-BAE present
Crepts present in left IAA
CNS-No findings
P/A-soft,non tender

Clinical pictures:

Investigations:

• Fasting Blood sugar
• Hemogram
•Complete urine examination
• ECG
• Chest Xray
• Colour Doppler 2D Echo
• Ultrasound

Provisional dignosis:
?Community acquired pneumonia 
?B/L lower lobe consolidation
?Pyelonephritis 
With H/O PTCA 1 and half year back
With K/C/O DM-type 2
Treatment:
IVF NS @150 ml/hr-bolus given
             @75 ml/hr- maintenance 
TAB.DOLO 650MG TID
INJ.NEOMOL 1G IV SOS
Temperature charting 4th hrly
INJ.AVIL 2CC SOS(IF CHILLS +)
GRBS monitoring 6th hrly
INJ.HUMAN ACTRAPID ACCORDING TO GRBS
TAB.ECOSPIRIN 75/20 MG PO OD
INJ.PIPTAZ 4G IV QID

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