a 32 year old male with Fever since 7 days

 This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.  

case presentation - 

A 32 year old male patient came to OPD with chief complaints of 
-Fever since 7 days 
-Stomach pain since 7 days 

History of presenting illness  -
Patient was apparently assymptomatic 7 days back then he developed fever which is insidious in onset , gradually progressive , high grade fever , increased during night , associated with chills and rigors , no aggravating factors , relieved temporarily on medication 
History of night sweats 
Then he developed pain abdomen since 1 week which was insidious in onset , gradually progressive , pain in right hypochondrium , right lumbar , umbilical region which was pricking type , non radiating , aggrevated on inspiration , non relieving factor 
H/o cough since 3 days insidious on onset , non productive 

No h/o post nasal drip , sore throat , running nose , nasal congestion , headache 
No h/o constipation , nausea , vomiting , loose stools , abdominal distension 
No h/o dypsnea , wheezing 
No h/o chest pain , palpitations , pnd,orthopnea , platypnea 
No h/o hemoptysis , hoarseness of voice , burning micturition 

Past h/o:
 
H/o of hospital admission in hospital 9 days back , where he was non relieved and came to our hospital 

Not a k/c/o hypertension , diabetes , asthma , epilepsy , tuberculosis


Personal h/o :

Diet - mixed 
Sleep - disturbed 
Appetite - normal 
Bowel and bladder movements - regular 
Addictions -  ocassionally drinks alcohol 
No smoking habits 
No allergies 

Family h/o :
No significant family history 

Treatment h/o :
Pleural tap done on 14.04.23 ( 20 ml ) and on 15.04.23 (30 ml )

General examination - 
Patient was conscious , coherent , cooperative 
Moderately built , moderately nourished 

No signs of  pallor 

Icterus - absent 







Cyanosis - absent 
Clubbing - absent 
Kolionychia - absent 
Lymphadenopathy - absent 
Edema - absent 

Vitals :
Pulse - 86 
Bp - 120/ 80 mmhg 
Temp - afebrile 
Rr - 16 cpm 

Systemic examination - 

Respiratory :

 Inspection - 
Trachea appears to Be midline 
Chest movements appears to Be equal 
Shape of chest appears to Be elliptical 
No scars , no sinuses , engorged veins 
No hallowing , no crowding of ribs , drooping of shoulder 

Palpation - 
All inspectory findings are confirmed 
No Local rise of temperature   
No tenderness 
Trachea - central 
Bilateral chest movements are equal 
No palpable swelling , masses 

Vocal fermitus -       Rt.              Lt

Supraclavicular :      N                      N
Infraclavicular :       N.                       N 
Mammary :        Decreased                N
Inframammary :  decreased.               N
Axillary :            Decreased.              N 
Infraaxillary :     decreased.               N 
Suprascapular :      N.                        N
Infrascapular :        N.                        N
Interscapular :       N.                           N


Percussion -



Auscultation - 


Per abdomen - 

Inspection - 

Shape of abdomen - appears to Be scaphoid 

Umbilicus - appears to Be inverted 

No scars , no swellings , engorged veins

No visible pulsations , no peristalsis 

Palpation - 

Local rise of temperature is seen 

Tenderness in right hypochondrium , right lumbar , umbilical region 

No mass felt 

Percussion - 

No h/o fluid thrill , liver span , shifting dullness 

Auscultation - 

Bowel sounds are heard 

Cardiovascular system - 

Inspection: 

No chest wall abnormalities 

No scars sinuses sinuses engorged veins 

Trachea appears to be central 

Apical impulse not visible 

Palpation: 

Apical impulse felt at 5th ics 1cm medial to midclavicular line 

No parasternal heaves 

No thrills 

Auscultation:

S1 s2 heard no murmurs 


Central nervous system -

Higher mental functions :intact ,normal 

Cranial nerves :normal 

Sensory examination: Normal sensations felt in all dermatomes 

Motor examination: normal tone,power in upper and lower limbs, normal gait 

Reflexes: B/l elicited 

Cerebella’s function: normal 

No meningeal signs were elicited 


Investigations - 




Fever chart 



Usg report 




Provisional diagnosis - 

Right sided Pleural effusion sec. To TB 

Mild hepatospleenomegaly 


Treatment:

Iv fluids NS 

Inj neomol 1gm iv 

Inj tramadol 1amp in 100 ml of NS

Inj pan 40mg 

T.azithromycin  500mg 

Tab ATT 

4 tabs H 340mg,R 680mg,Z 1700mg,E 1020mg 

Tab PCM 650mg 

Syrup grilintus 15ml 

Tab pyridoxine 25mg 

Inj diclofenac I.m 








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