28 yr old male with Fever, Cough and cold

 2nd internal assessment

CH.SWAGATH

ROLL NO.31

Long case :

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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.

28 yr old male patient came to opd with chief complaints:

1.Fever since 4 days

2.Cough and cold since 3 days

HOPI :

Patient was apparantly asymptomatic 10 yrs back then he had an accident and went to govt hospital then diagnosed as rupture of liver and underwent surgery for it

Then after 5 yrs he went to govt hospital with chief complaints of vomitings , stomach pain in the right side of abdomen and was diagnosed with acute appendicitis (antibiotics were given) was referred to our hospital where appendectomy was done.

Now he presented to opd with fever since 4 days which is sudden in onset , intermittent (evening rise of temperature) for which he took rest

Fever is associated with chills and rigor.

Then next day he developed cough which is intermittent and productive. Sputum is in yellow color and non blood tinged.

Nocturnal variation is seen(increased during nights).No postural variation

Shortness of breath is seen following cough.

Past history: 

Not a known case of TB , Asthma , Hypertension, Epilepsy, DM

Surgical history:

Surgery of ruptured liver -10 yrs ago

Appendectomy -5 yrs ago

Personal history:

Diet - Mixed

Appetite - Normal 

Sleep- Adequate

Bowel and bladder movements -Regular

No addictions 

Family history:

No significant family history

GENERAL EXAMINATION:

patient is conscious,coherent and cooperative

Well orientated to time, place and person

Moderately built and nourished

Temperature - afebrile

Heart rate - 75 bpm

Respiratory rate -15 cpm

BP -120/70 mm of hg

No pallor, Icterus ,cyanosis, clubbing and lymphadenopathy

SYSTEMIC EXAMINATION:

Respiratory system 

Inspection:

On inspection shape of chest is normal and bilaterally symmetrical with no scars and centrally place trachea

Respiratory movements are symmetrical on both sides

Palpation:

All the inspectory findings are confirmed

Chest movements are symmetrical

Vocal fremitus:                                                   

Supraclavicular same on both sides  

Infraclavicular same on both sides

Supra Mammary same on both sides

Infra mammary same on both sides

Suprascapular same on both sides

Infrascapular same on both sides

Interscapular same on both sides

Percussion :

Resonant note is felt on both sides in all areas

Auscultation :

Normal vesicular breath sounds in all areas 

No added breath sounds

CVS - S1 S2 heard

CNS -No focal neurological deficit

Per abdomen - soft and non tender

INVESTIGATIONS:

ECG

HEMOGRAM

LFT

RFT

Provisional diagnosis:

Respiratory tract infection ?