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 

INVESTIGATIONS:

  PROVISIONAL Diagnosis : DIABETIC KETOACIDOSIS WITH 
                       ? LEFT  LOBE PNEUMONIA 
                     WITH DENOVO TYPE 1 DM 

TREATMENT 
 1) IVF-NS  @100ml /hr 
 2) INJ. HAI INFUSION @4ml/hr 
3)INJ PAN 40mg iv /od 
4)INJ ZOFER 4 mg iv/sos 
5)INJ NEOMAL 1gm iv/sos
6)TAB PCM 650mg /po/sos
  
Day 1
27 M with c/0 chest pain since 3 days;cough with expectoration (hemoptysis)since 2 days  and high grade fever since 2 days.
SOB grade 2-3 since 2 days.
O
 Bp-120/70
Pr-116
Cvs-s1s2 heard
Rs-BAE present 
Left-MA,IAA,ISA-coarse crepts present and decreased air entry 
Temp-101f
GRBS-90mg/dl(Hai@1ml/hr)
A-DKA
Left lower lobe pneumonia
Denovo detected type 1DM
P-continue insulin infusion till acidosis resolved.
Plan to bridge to subcutaneous insulin 
DAY 2

Day 3
S - cough decreased ,1 fever spikes yesterday  ,chest pain subsidied appetite improved 
Pr-102
Temp-100f
A-DKA(resolved)
Right upper lobe cavity present with left lobe surrounding consolidation
?pulmonary Koch's
P-waiting for CBNAT report

Day 4

S - cough decreased ,2 fever spikes yesterday  ,chest pain subsidied appetite improved 
A-DKA(resolved)
Right upper lobe cavity present with left lobe surrounding consolidation
?pulmonary Koch's TRUNAT Report awaited 
P-changed antibiotics to ciproflaxin

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