32 year old male with fever under evaluation

 32 year old male with fever under evaluation

32 year old male patient came to casualty with chief complaints of:

Fever since 3 months

Cough since 3 months

Vomitings since yesterday 

History of present illness :

Patient was apparently asymptomatic 3 months back,then he developed fever which was of high grade associated with headache, chills,continuous,more during night time.

C/O cough since 3 months,dry,no hemoptysis. 

Associated with shortness of breath. 

C/O vomitings since previous day, multiple episodes. Non blood stained, non bilious.

H/O weight loss present. 

H/O loss of appetite present. 

H/O paraplegia 3 months back,admitted, recovered with in 2 months.No bladder and bowel involvement. 

Past history:

H/O koch's 5 years back,used ATT for 4 months and stopped.

H/o paraplegia 3 months back, admitted and recovered a within 2 months, no bowel or bladder involvement. (?GBS)

H/O multiple suicide attempts present. 

Not a k/c/o DM,HTN,asthma,epilepsy,CAD.

Personal history :

Diet-mixed

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular

Alcoholic, stopped 1 and half year back

Smoking 1 pack/ day

General examination:

Vitals on admission:

Temperature-98.8 F

BP-100/80mmhg

PR-88 bpm

RR-17 cpm

Systemic examination:

CNS oriented to t/p/p 

                    Right     left

Power         

Upper limb   4/5     4/5

Lower limb  4/5      4/5

Reflexes 

Biceps          +2       +2

Triceps              -    -

Supinator          -    -

Knee                  -     -

Ankle                 -      -

Plantar flexor    extensor

Thoracic spine tenderness (+)

Referral of Department of Pulmonology i/v/o Cough since 3 months with h/o Pulmonary koch's used ATT for 4 months and stopped. Current cxr shows B/L cavities with sputum for AFB positive. 

Advised- To start ATT acc to FDC guidelines, T. Mucinac 600mg 1 tab in 1 glass water po/Tid, high protein diet, 2 egg a day.

 Dx- fever under evaluation with ?Pulmonary koch's (past h/o ?GBS (AMSAN TYPE)), past h/o peripheral neuropathy with past h/o pulmonary TB (?defaulter)

Treatment:

1)Tab.PCM 650 mg PO/TID

2)Temperature charting 4th hrly

3)Inj.Optineuron 1 amp in 100 ml NS/IV/OD

rx: 

Inj. Optineuron 1amp in 100ml NS IV/od

Inj. Neomol 100ml iv/tid

T. Dolo 650mg po/tid

T. Mucinac 600mg 1tab in q glass water po/tid x3days

Syp. Ambroxyl 15ml po/tid

High protein diet

2 egg whites a day

Temp charting 4th hrly

Bp/PR charting 

DX- Pulmonary koch's rifampicin sensitive