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
Provisional diagnosis:
Respiratory tract infection ?
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