50 yr old male with cough and fever since 7 days

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CHIEF COMPLAINTS

Patient came with chief complaint of cough since 

7 Days, Fever since 7 days, with difficulty in breathing since 7 days

HOPI

Fever since 15-days high grade-not associated with chills and rigor, evening rise + Associated with sweating

Cough since 7- days associated with less amount of sputum, mucoid. blood tinged aggravated on changing position from lying down to sitting position, no reliving factors

SOB grade - I MMRC -: 7 days more associated with cough, relieved on rest not associated with wheeze

K/C/O: Dm+ since 2years 

H/o RTA 1 1/2 year back
Fracture of neck of femur with dynamic hip screw surgery done in outside Hospital.Immobilisation 1 month to 1-1/2 year back

H/o -electrocution 

4-years back - Burns both hands

N/K/C/O HTN,CAD ,Br Asthma ,epilepsy 

No H/O similar complaints in the past 

No past H/O TB, loss of appetite, loss of weight

PERSONAL HISTORY

Patient is Binge Alcoholic and Smokes 18 cigarettes in a day later he started smoking Bedi Suttas(high tobacco cigar) in day. 

Patient attendant said that their neighbour has TB ( who is son in law of him )

And Patient visits weekly 4 times to his home & spend with him approximately 1-hour a day

Patient started to have fever since 10 days at night time with burning sensation all over the body

Patient started to have unbearable pain at lower back  during cough .and always needed help from attendants to hold his back during coughing

PAST HISTORY

K/c/o DM since 2 years was diagnosed during his RTA treatment and is on regular Glimipride 1mg &Metformin 500mg medication since then. He has no history of hypertension, diabetes ,asthma, epilepsy, tuberculosis.

GENERAL EXAMINATION 

Patient is conscious, cooperative ,coherent and oriented with time , place , date.
Slightly pallor, 
No icterus, cyanosis, clubbing, lymphadenopathy, edema was noted

VITALS:
Bp-80/40 mm Hg
Pr-102 bpm
Rr-25 cpm
Temperature:99.5
Spo2: 98%@RA
GRBS- HIGH

Sputum sample

Burn in both hands

Slight discoloration on lower back

Surgical implant leg scar

INVESTIGATIONS

6.5.23

7.6.23

Hrct findings

6.6.23

7.6.23

8.6.23

Urine for culture

9.6.23

Sputum for culture

10.6.23

Chest x ray 10.6.23

11.6.23

12.6.23

13.6.23

SYSTEMIC EXAMINATION

CVS:S1 S2 heard , No murmurs 

CNS:

No focal neurological deficit

RS:
Breath movements -abdominal thoracic
In infra scapular area of left lung

Inspection: chest shape normal, 

Dysponea - present

Palpation: trachea -central

Auscultation: basal crepitations are heard