65M with fever since 10 days

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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 65 year old male patient from mallepalli, nalgonda came with chief complaints of 

•fever since 10 days



HISTORY OF PRESENT ILLNESS.


Patient was apparently asymptomatic 2 months back after which he developed shortness of breath which was insidious in onset, grade 1 not associated with orthopnea, no diurnal or seasonal variations.


He complains of fever since 10 days which was insidious in onset, low grade, associated with chills and rigors, evening rise of temperature is seen, alternate day fever .


No complaints of cough, chest pain, chest, tightness, hemoptysis.

no history of vomitings, pedal edema, burning micturition, decreased urine output.


PAST HISTORY 

No similar complaints in the past 

Not a known case of diabetes,hypertension,epilepsy,asthma,tuberculosis,thyroid disorder.


FAMILY HISTORY

No significant family history 


PERSONAL HISTORY 

Diet -mixed

appetite-decreased

bowel and bladder movements -regular

sleep-adequate 

addictions- alcohol 

                 2  chutta every day since 40 years.


DAILY ROUTINE 

Occupation - farmer

stopped working since 7 years 

wakes up at 6 am

does his daily routine 

drinks tea or milk at 7.30 am

has rice and curry for breakfast at 9 am

lunch at 2 pm

sleeps for 2 hrs 

takes tea at 6 pm

dinner at 8 pm

sleeps by 9.30pm.


GENERAL EXAMINATION 

patient is conscious,coherent and cooperative 

well oriented to time,place and person

thin built and moderately nourished 


 No pallor, icterus, cyanosis, clubbing, lymphadenopathy,pedal edema.


VITALS 

BP -110/70 mmhg

TEMP- afebrile

RR-20 cpm

PR- 100bpm

spO2- 98% 


SYSTEMIC EXAMINATION

CVS- S1S2 heard, no murmurs 

CNS- No focal deficits 

PA- soft, non tender


RESPIRATORY SYSTEM 


URT: 

Nose- no polyps, dns

oral cavity- poor oral hygiene 

Post pharyngeal wall- normal


LRT


Inspection

Shape of chest : bilateral symmetrical,elliptical 

trachea: central

supra and infra clavicular hollowness

chest expansions equal on both sides

no crowding of ribs

no drooping of shoulders

no wasting of muscles

no usage of accessory muscles of respiration

apical impulse not seen

no scars,sinuses, engorged veins

dry scaly skin seen

no kyphosis ,scoliosis



Palpation:

all inspectory findings are confirmed

no local rise of temperature 

no tenderness 

trachea central

apex beat left 5th ICS,medial to MCL

TVF increased at right InfarClaviclaruArea, Mammary Area.


diameters

ap: 19cm

transverse: 22 cm

chest circumference: I 79 cm

                                      E 75cm



Percussion

resonant, dullness in right mammary area


auscultation 

BAE+

NVBS heard

BBS at right Infraclavicular area

VR increased at right ICA, MA


















INVESTIGATIONS 





CBNAAT positive



























PROVISIONAL DIAGNOSIS 

Right upper lobe and middle lobe consolidation Secondary to TB 



TREATMENT 

inj Augmentin 1.2 gm IV TID

inj Pan 40 mg IV OD

inj neomal 100 ml IV

tab PCM 650 mg PO TID

syp aptivate 2 tsp PO BD

monitor vitals,

tab Azee 500 mg PO OD

inj ceftriaxone 1gm IV BD

IVF DNS 500 ml stat

IVF NS 75 ml/ hr



added tab nodosis 500 mg PO BD

protein powder in milk PO BD



started ATT

Tab isoniazid 170 mg PO OD

Tab rifampicin 340 mg PO OD

Tab pyrazinamide 850 mg PO thrice weekly

Tab ethambutol 510 mg PO thrice weekly.



























 



              

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