32 year old male with fever and pain abdomen

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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.

A 32 M farmer by occupation from miryalaguda came to GM OPD with chief complaints of:

Pain abdomen Since: 7 days
Fever - 7 days.
cough -7 days

HOPI : Patient was apparently asymptomatic 7 days back, then he developed fever which was insidious in onset gradually, progressive, the fever was high grade in nature, increased during right, no aggravating factors & temporarily releived on medication. He also developed Pain in the abdomen; at right hypochonchiac region,Pain was of pricking type. The Pain was aggravated on deep inspiration & no releiving factors. Cough since 7 days insidious in onset gradually progressive non productive in nature no aggravating and releiving factors.

No Chest tightness, hemoptysis; SOB, Orthopnea, PND.
No Night Sweats, Post nasal drip.
No  Constipation , Nausea, Vomiting, Loose stools, Blood in  stools,No Abdominal distention.No increased or decreased output.
No  Palpilations No hoarseness of voice.

PAST HISTORY:

History of Hospital admission 10 days back stayed for 3 days was not satisfied with the treatment then he Came to our hospital.

N/K/C/O DM, HTN, asthma, epilepsy, TB, Thyroid disorders.

PERSONAL HISTORY:

DIET: Mixed

APPETITE: normal

SLEEP: normal

B&B: normal

ADDICTIONS: ALCOHOLIC SINCE 15 YEARS DRINKS OCCATIONALLY ONCE OR TWICE A MONTH, DRINKS QUARTER TO HALF  A BOTTLE PER OCCASION.

NON SMOKER.

ALLERGIES: Not known.

TREATMENT HISTORY: Not significant.

FAMILY HISTORY: Not significant.

G/E:

Patient is conscious, coherent, cooperative well oriented to time place and person .Moderately built, moderately nourished

Pallor: absent 

Icterus: absent 

Cyanosis: absent 

Clubbing: absent

Generalized lymphadenopathy: absent

Bilateral pedal edema: absent  

Vitals:

Bp:120/80 mmhg 

Pulse rate: 80 bpm 

RR: 18 cycles per min

Temp: Afebrile.

SYSTEMIC EXAMINATION:

P/A: 

INSPECTION:

There Shape of abdomen- scaphoid

Umbilicus- inverted

No Scars, Sinuses and engorged veins.

No visible palsations, peristalysis

Palpation:

No local rise of temp

tenderness - right hypochondrium

No masses felt  Spleen X Liver X

Percussion - No dullness

No Fluid thrill

No Shifting dullness

Aus -Bowel sounds heard.

RESPIRATORY SYSTEM EXAMINATION:

INSPECTION:

Trachea -central.

chest movements - Equal.
shape - elliptical.
No Scars, Sinuses and Engorged Veins.

No hollowing or crowding of ribs
drooping of shoulders

PALPATION:

All inspectory findings are confirmed.

No Local rise of temp
No tenderness.
trachea- central
Bilateral chest movements movements - Equal

TACTILE VOCAL FREMITUS: DECREASED IN MAMMARY, AXILLARY, INFRA AXILLARY AREAS IN RIGHT SIDE.

PERCUSSION: DULL NOTE IN RIGHT MAMMARY, INFRA AXILLARY ,AXILLARY AREAS 

TIDAL PERCUSSION: DULL NOTE FROM 6TH ICS.

AUSCULTATION: 

decreased breath sounds in right axillary, mammary, infraaxillary areas. Left side normal.

CVS: S1,S2 heard, no murmurs.

CNS: no focal neurological deficits

 provisional diagnosis: pleural effusion right side.

INVESTIGATIONS:

DIAGNOSIS: PLEURAL EFFUSION SECONDARY TO TB right side

TREATMENT: