32 year old male with fever and pain abdomen



 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 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:



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