37 year old male with fever

 

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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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

A 37 year old male came to opd with chief complaints of fever since 5 days ,(cough cold generalized weakness,headache) shortness of breath since 3 days and loose stools since 3 days 

HOPI:

 Patient was apparently asymptomatic 5 days back then developed high grade fever ,intermittent in nature, associated with chills ,rigor ,generalized body weakness which relieved on taking medication .he also have complaints of cough which is non productive in nature,not associated with expectoration ,no diurnal or positional variation of cough,it is releived on taking cough syrup ,from last 3 days he is experiencing shortness of breath grade 3 according to patient . he also had 5 episodes of loose stools which is non blood stained,non mucoid ,liquid in consistency ,non foul smelling in nature,not associated with abdominal pain and vomitings.

past history:  he is not a K/C/O HTN, CAD, epilepsy,asthma ,Tb

personal History:

DIET: Mixed

APPETITE: good

BOWEL AND BLADDER: regular

SLEEP: adequate

ADDICTIONS:alcohol regularly

family history: no significant family history.

GENERAL PHYSICAL EXAMINATION:

patient is conscious ,coherent,cooperative well oriented to time ,place and person,he is a obese and nourished

no signs of pallor, icterus,clubbing ,cyanosis,lymphadenopathy

B/L Pedal edema is present

vitals at the time of admission:

TEMP: 98.9 ° F

BP:110/80 mm Hg

pulse: 110 bpm 

RR:22 cpm

per abdominal examination : generalized distension of abdomen,flanks full,all regions move equally with respiration,skin appears normal

umblicus: central and inverted

no visible scars ,sinuses,hernial orifices,pulsation or peristalsis

palpation is done in supine position with limbs flexed, no local rise of temperature or tenderness 

liver is palpable

shifting dullness ,fluid thrill could not be elicited

(abdomen is soft ,non tender, with hepatomegaly .)

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

shape of the chest: normal

trachea appears to be central

small scar is seen on the chest

small scar is seen on the chest

6/9/22