32 year male with fever and stomach pain

 

32 year male c/c fever stomach pain

 

32 year old male farmer by occupation resident of suryapet came to opd with 

Chief complaints : 

Fever since 1 week 

Stomach pain at right side since 1 week



HOPI

Patient was apparently asymptomatic 1 week back then he developed fever which is sudden in onset ,continous,gradually progressive associated with chills and rigors,evening rise of temperature was present with night sweats.no aggregating factors ,temporarily relieved by medication 


Patient also complained of abdpmen pain since 1 week in right hypochondriac,rt.lumbar,umbilicus region aggrevated on inspiration and relieved by rest


H/O cough since 3 days ,insidious in onset,non productive type,non blood stained,non foul smelling

No h/o post nasal drip,cold,hoarseness of voice,noseblock

No h/o dyspnea,chestpain,palpitations

No h/0 PND,orthopnoea

No h/o nausea vomiting,abdominal distension,constipation,loose stools


Past history 

H/o admission in hospital due to same complaints 

Not a K/C/O DM,HTN,TB,asthma,CAD,thyroid disorder 


PERSONAL HISTORY:

Mixed diet

Adequate sleep

Regular bowel and bladder movements

No smoking and no allergies

Ocassional alcohol consumer


FAMILY HISTORY:

not significant

GENERAL EXAMINATION:

Patient is c/c/c


No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.


Temp-Afebrile 


BP- 130/90 mmhg


PR - 90bpm


RR - 18cpm


R/S - inspection:

Trachea appears to be normal - Central 


shape of chest - elliptical 


Movements of chest appear to be bilaterally equal


No scars , sinuses present.

No drooping of shoulder

No engorged veins , swellings seen

No hallowing seen

No crowding of ribs


Palpation:

All inspectory findings are confirmed

 rise of temperature present

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt


vocal fremitus 


                                            RT.            LT

SUPRA CLAVICULAR       Normal.      Normal

INFRA CLAVICULAR.       Normal.       Normal

MAMMARY.                       Decreased.  Decreased 

INFRA MAMMARY.           Decreased.  Decreased 

AXILLARY.                         Decreased.   Decreased 

INFRA AXILLARY.             Decreased.  Decreased 

SUPRA SCAPULAR.         Normal.     Normal

INFRA SCAPULAR.         Normal.      Normal

INTER SCAPULAR.          Normal.    Normal 

PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       Dull.          resonant

INFRA MAMMARY.           Dull.        .  resonant

AXILLARY.                         Dull.          resonant

INFRA AXILLARY.             Dull.           resonant

SUPRA SCAPULAR.       Resonant  resonant

INFRA SCAPULAR.         resonant   resonant

INTER SCAPULAR.          resonant   resonant


Auscultation 

Bilateral airway entry present

Normal breath sounds heard


PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       NVBS.        NVBS

INFRA CLAVICULAR.       NVBS.         NVBS

MAMMARY.                       decreased    NVBS

INFRA MAMMARY.           Decreased    NVBS

AXILLARY.                         Decreased    NVBS

INFRA AXILLARY.             Decreased    NVBS

SUPRA SCAPULAR.       NVBS.             NVBS

INFRA SCAPULAR.         NVBS.             NVBS

INTER SCAPULAR.          NVBS.            NVBS  

Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard



Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


Central nervous system:

Conscious

Normal speech.

No neurological deficit found.







Provisional diagnosis 


Pleural effusion right side 

Secondary to tuberculosis












Comments

Post a Comment

Popular posts from this blog

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

 I'm SHAIK SAMEER, a under graduate medical student from Telangana, India. I m here to share my experience that i have learned in the past years under the guidence of my beloved professor of general medicine. CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. MY FIRST PATIENT INTERACTION I FIRST INTERACTED WITH MY PATIENT IN THE AMC WARD. HE WAS SEVERELY DEHYDRATED AND WAS IN SEVERE PAIN.SO I WENT NEAR HIM AND ENQUIRED ABOUT HIS MEDICAL CONDITION. I HAVE TAKEN A DETAILED HISTORY FROM THE PATIENT TO FIND OUT THE EXACT CAUSE AND THE CONDITION HE IS FACING. FROM  THE HISTORY I GOT TO KNOW THAT H
Read more
Image
  43year old male came with the      chief complaints of  Fall due to loss of consciousness on 4/4/23 Hopi- Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite . No history of fever, vomiting, neck stiffness, neck pain , and headache .  No history of visual disturbances.  No history of head trauma .  No history of sob , chest pain , palpitations, orthopnea .  Past history  K/c/o DM since 4years and was on medication  K/c/o HTN since 3 years Not a k/c/o asthma , tb , epilepsy and thyroid disorders  Personal h/o  Appetite- normal Diet - mixed Bowel and bladder - regular Any known Allergies- absent Addictions- alcohol- regular 180 ml /day , last intake yesterday morning.  Family h/o - not significant On general examination -  patient is conscious,
Read more

35 YEARS MALE WITH VOMITING ,GENERALISED WEAKNESS AND HICCUPS

Image
35 years male patient with     vomiting , generalised weakness  and hiccups                                 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. is an online e log book to discuss our patient de-identified health data shared after taking his / he
Read more