28 year old male with fever, cold and cough



 2nd INTERNAL ASSESSMENT

HARTHIK CHOPPA

ROLL NO 56   

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 28 year old male resident of Lingotum farmer by occupation came to general medicine opd with cheif complaints of:

1) Fever since 5 days

2) Cough since 4 days

3) Cold since 4 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently assymptomatic 10 years back then he suffered from an accident and underwent liver surgery for it.

Then after 5 years back hewas admitted to government hospital with cheif complaints of vomitings, stomach pain in the right abdomen area and was diagnosed with acute appendicitis where he was given antibitotics and referred to our hospital where he underwent appendectomy.

Now he presented to opd with fever since 5 days which is sudden in onset, intermittent aggravated during night times and relieved in the morning. Fever is associated with chills and rigor.

The next day he developed cough which was sudden in onset, productive.

Sputum was yellow in colour and non blood tinged

Then he developed cold same day as cough which was sudden in onset, associated with nose block

 on the first day.

PAST HISTORY

Not a known case of TB, epilepsy, Hypertension, Diabetes mellitus, 

SURGICAL HISTORY

History of liver surgery 10 years back 

History of appendectomy 5 years back

PERSONAL HISTORY

Diet: Mixed

Apetite: Normal

Bowel and Bladder movements: Normal

Sleep: Normal

No addictions

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative

Moderately built and nourished

No pallor, icterus, clubbing, cyanosis, lymphadenopathy and edema









VITALS

Temp: Afebrile 98.5F

Heart rate: 74 bpm

Respiratory rate: 14 cpm

Blood pressure: 120/70 mmHg

Pulse: Normal rate and rhythm

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 and S2 heard

CNS: No focal neurological defects

INVESTIGATIONS:

HEMOGRAM:

LFT:




SERUM CREATININE:


SERUM ELECTROLYTES:



ECG:



ULTRASOUND:


PROVISIONAL DIAGNOSIS:
Respiratory tract infection and cholelithiasis.







Comments

Post a Comment

Popular posts from this blog

A 45 year old male with chest pain

Image
Patient came with chief complaints of chest pain 1 episode 6 days back Patient was apparently alright 10 to 12 years when he developed increased drowsiness for which he consulted a doctor and was diagnosed to have hypothyroidism for which he used medication for 2 to 3 years and stopped it.he developed generalised body pains more on the neck and back insidious in onset, intermittent aggravated on working and relevied on taking rest.  Then 1 week back after his dinner (non veg) he started feeling tightness in his chest(like acidity in patients words) and started feeling hot and his breath became heavy for which he tried to on the fan and became unconscious as he got up. The pain was localised non radiating. When he got unconscious his family members observed that he was profusely sweating and pass urine involuntarily following which his family members took him to the hospital for which treatment was done for coronary artery disease, acute inferior wall mi with EF 45% He later got con...
Read more

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE

 MAY 30TH 2023 This in Harthik choppa a medical student from India. Welcome to my blog where you can see how my general medicine changed my view of seeing general medicine as a mere subject which has to be studied for the sake of exams to general medicine being an interesting, immersive journey which covers each and every aspect of our amazing human body. We had an open platform where we could discuss things and we approached our HOD sir and seniors directly many times where our doubts were cleared with an open mind without any judgement. As medical students we learned a lot of different ways to diagnose and treat a patient in different scenarios practically bedside rather than studying books for hours and hours. I am very much excited to share this journey over the past 3 years Coming to my first case,  It was a 65 old female who was quite alright when I saw her my first impression on the lady was she is perfectly alright so I was intrigued on why she came to the hospital as ...
Read more

60Y old male with sob, abdominal distention and bilateral pedal edema since 4 days

Image
  Patient came with chief complaints of shortness of breath since 4 days, pedal edema since 4 days and abdominal distention since 4 days Patient was apparently asymptomatic 5 years back when he had an injury to the left leg by a thorn prick for which doctor advised him to keep ice over it. He did this for 5 days when he noticed swelling accompanied by blebs. Swelling was localised and associated with pain which was non radiating, no know aggravating or releiving factors for which he was admitted and dressing was done for 1 week and later ok discharged after the swelling had reduced. During this visit to the hospital he was given a pint of blood transfusion due to decreased heamoglobin count. The patient complains of neck pain from 10 years has history of lifting heavy weights on shoulders, non radating, no known aggravated and releving factors. Some releif on using collar. Use it when he is unable to bear it. H/o knee pain since 10 years bilateral non radiating aggravates on walkin...
Read more