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.







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