39 year old male with Fever and Cough
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog 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 diagnosis and treatment plan
A 39 year old male who is a labourer by occupation came to opd with the cheif complaints of
1. cough since 1 week
2. fever since 1week
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1month back then he developed cough initially with sputum and later it turned to dry cough(non productive cough )since 1 week.for which he got admitted and diagnosed as left pleural effusion and now he is presenting with dry cough since 1 week which is gradual in onset and non progressive more in night and no aggravating and receiving factors. He also complains of fever since one week which is insidious in onset and low grade ,evening rise of temperature is present and subsided by medication .
No history of chest pain ,decreased urine output,sweating and palpitations.
HISTORY OF PAST ILLNESS:
Patient had a history of similar complaints in the past for which he has diagnosed with left pleural effusion and pleural tap done (1500 ml)
Patient is a known case of diabetes since 7 years on Glimi M1 ,not a known case of hypertension ,thyroid disorders,CAD ,TB,epilepsy.
PERSONAL HISTORY:
Patient is a labourer by occupation,he wakes at 6Am and goes to wash room freshup and drinks tea at 8am and at 9 an he goes to his labour work and 8to 1 am he does his work at 1 am he eats his lunch an after 1 am he again starts his work and he complets work by 5 pm and reaches home by 6 pm ,from 6 pm to 8 pm he spends his time by watching TV and after 8 he eats his dinner and sleeps at 9pm
Diet :mixed
Appetite:normal
Sleep:adequate
Bowel and bladder :Regular
Addictions:has the habit of chewing tobacco.
FAMILY HISTORY:No history of similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
Moderately built and moderately nourished.
No pallor,icterus,cyanosis,clubbing,lymphadenopathy and edema.
Vitals:
BP:110/80MMHG
RR:18CPM
PR:86BPM
TEMP:99.6F
SYSTEMIC EXAMINATION:
EXAMINATION OF RESPIRATORY SYSTEM:
UPPER RESPIRATORY TRACT:
Nose :Normal.
No polyps
No Dns
No posterior pharyngeal wall congestion
No upper Respiratory tract infections.
LOWER RESPIRATORY TRACT:
Inspection:Trachea central
Shape of chest :symmetrical
Movements of chest:normal
No droopy or wasting of muscles.
No scars ,sinuses or engorged veins.
Abdominal thoracic type of breathing.
No kyphosis and scoliosis.
Palpation:
Trachea :central
Temp :Afebrile
All inspectory findings are confirmed
AP DIAMETER:30 CM
TRANSVERSE DIAMETER:26 CM
ON INSPIRATION:97 CM
ON EXPIRATION:96CM
RT HEMITHORAX:45CM
LT HEMITHORAX:45CM
Chest movements:Equal on both sides.
Apex beat on the left 5th intercostal space 1 lateral to mid clavicualr line.
PERCUSSION:Direct :Resonant
Indirect :Dull at left LAA,LSA.
AUSCULTATION:BAE Present
Normal vesicular breath sounds are present.
Decreased breath sounds on LAA AND LSA ON LEFT SIDE .
CVS:
Jvp not raised
Inspection:
Shape of chest - elliptical
No visible pulsations
No engorged veins
Apical impulse not visible
Palpation:
Apex beat present over the left 5th intercostal space medial to midclavicular line
No parasternal heave
No precordial thrill
No dilated veins
Auscultation:
S1 S2 heard ,No murmurs
Per Abdomen:
Inspection:
Shape - scaphoid
Flanks - free
Umbilicus - inverted
All quadrants moves equally with respiration
No engorged veins, visible pulsations
Hernial orifice are free
Palpation:
No local rise of temperature
Abdomen is soft and non tender
No palpable spleen and liver
No other palpable masses
Percussion:
Resonant
Auscultation:
Normal bowel sounds heard
CNS :
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Rt- UL. LL. Lt- UL. LL
Bulk - normal N. N. N
Tone - N. N. N. N
Power - 5/5. 5/5. 5/5. 5/5
Reflexes:
UL. LL
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 2+
Knee 2+. 2+
Ankle. 2+. 2+
Sensory system: intact
Co ordination is present
Gait is normal
No Cerebellar signs
No signs of meningeal irritation
Clinical pictures:
Investigations:
Comments
Post a Comment