55 yr old patient came with complaints fever since 2 months

14/06/23


Hi, I am shaik karishma , 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered 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 a diagnosis and treatment plan. 

CHEIF COMPLAINTS 

55yr male Tiles construction worker came with complaint of Generalised weakness,fever and dry cough since 2 months 

HISTORY OF PRESENT ILLNESS 
Patient was apparently asymptomatic 2months back then he had insidious onset of feverwhich was  intermittent and relived on medications,it was not associated with chills and rigors.
Fever is associated with generalised weakness(unable to do his routine job works) and dry cough(which is insidious onset, intermittent,relived on medication, no aggravating factors, not associated with positional or seasonal variation)
History of weight loss, loss of appetite present.

PAST HISTORY
Patient had pulmonary tuberculosis 25years back,used ATT for 6months.
No DM/HTN/CAD/CVA/EPILEPSY/Thyroid disorders
No blood transfusions and surgeries 

PERSONAL HISTORY
Married
Mixed diet 
Decreased apetite since 2 months 
Adequate sleep 
Normal bowel 
Normal micturition 
Takes alcohol 90ml whisky per day for past 30years
Tobacco chewer for 30years
No known allergies 

FAMILY HISTORY
No history of similar illness in the family

GENERAL EXAMINATION
Patient is conscious, coherent,co-operative
Moderately built and nourished
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy,Pedal edema

VITALS :-

PR:-84bpm
BP-120/80mmhg,
RR-28/min,Abdominothoracic type 
Temperature:
SPO2 :  
Grbs-



Oral candidiasis present
SYSTEMIC EXAMINATION
Inspection :
Trachea appears to be in centre
No scars, sinuses,dilated veins over the chest
Apical impulse not visible
Chest-Bilaterally symmetrical/Elliptical
Chest movement Decreased on right side
Spinal deformity present -->Dorsal thorassic vertebrae Gibbus +
Palpation :
Trachea--Central
Apex beat--1.5cm medial to mid clavicular line in the left 5th intercostal space
Respiratory movements --decreased on right side with respiration
Chest Measurements :
 Anteroposterior diameter-18cm
Transverse diameter-28cm
Ratio of AP diameter : Transverse diameter 
Chest circumference :85cm
 Vocal fremitus : Increased on right side of chest 
Percussion : Resonant
Auscultation:
Supraclavicular & Infraclavicular : Bronchial breath sounds +
Vocal Resonance:increased on right side of chest
Inspiratory crepts present on the right side of chest
OTHER SYSTEM EXAMINATION

CARDIOVASCULAR:
Elliptical & bilaterally symmetrical chest
No visible pulsations/engorged veins on the chest
Apex beat seen in 5th intercostal space medial to mid clavicular line
S1 S2 heard
No murmurs

PER ABDOMEN :
Scaphoid
No visible pulsations/engorged veins/sinuses
Soft,non tender,and rigidity, no hepatosplenomegaly
Bowel sounds heard

INVESTIGATIONS



Sputum for AFB & CBNAAT : Negative

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