50/M WITH FEVER ,LOSS OF APPETITE AND PAIN ABDOMEN WITH Z+ve
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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.
UNIT 1
AMC
DOA:12/06/23
This is a case of 55 year old male who is construction worker(floor tile worker) by occupation and resident of Nalgonda district who came with chief complaints of
- YELLOWISH DISCOLOURATION OF EYE SINCE 1 MONTH.
-FEVER SINCE 1 MONTH.
-LOSS OF APPETITE SINCE 20 days.
-PAIN IN THE ABDOMEN SINCE 20 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic a month ago then he noticed yellowish discolouration of eye for which he used HERBAL MEDICINE and then he complained of fever which was low grade and continuous type not associated with chills and rigours.
The patient later developed pain abdomen which was insidious in onset and gradually progressive. She localised the pain to her right upper quadrant. It was sharp in nature non radiating. There are no aggravating and relieving factors.
PAST HISTORY:
Patient is a known case of PULMONARY TUBERCULOSIS 25 years ago for which he used medication for 6 months.
Not a known case of DM, HTN, CVA, CAD, Thyroid disorders, Asthma and epilepsy.
PERSONAL HISTORY:
Daily routine: He wakes up at 5 in the morning and freshens up. Have tea at 8 AM and goes to work by 9 in the morning. He takes lunch at 1:30 PM. Around 5 PM he comes back to his house.
He has dinner by 8 PM and goes to bed at 9:30 PM.
DIET: MIXED.
APPETITE: DECREASED SINCE 20 DAYS.
SLEEP: ADEQUATE.
BOWEL AND BLADDER: IRREGULAR
(once in 3 days and watery since 10 days)
ADDICTIONS: occasional drinker since 35 years(90ML every time) and chews tobacco from when he was 25 years old.
FAMILY HISTORY:
Not significant.
CLINICAL EXAMINATION:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
The patient was conscious coherent and cooperative. Well oriented to time place and person.
Pallor - present
Pallor - present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: absent
VITALS:
TEMP:97.2F
PR:106bpm
RR:24cpm
BP:100/60
Spo2: 99% at RA
GRBS:114mg/dl
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appear normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 5th Intercoastal space
space
Auscultation :
S1,S2 are heard
no murmurs
CNS:
Higher mental functions :intact
Cranial nerves intact
Motor examination: R L
Bulk. N N
Tone. N N
Power. N N
Reflexes:
Biceps. 2+ 2+
Triceps. 2+ 2+
Supinator 2+. 2+
Knee 2+ 2+
Ankle. 2+. 2+
Sensory examination:Normal
No meningeal signs
PER ABDOMEN::
**Shape of abdomen-scaphoid
**Tenderness-No
** Palpable mass-No
** Liver- Not palpable
**Spleen - Not palpable
**Bowel sounds - Normal
Treatment::
1.IV FLUIDS@75ML/HR
3.INJ NEOMOL 1GM IV SOS
3.INJ MONOCEF 1GM IV/BD
4.TAB PCM 650MG PO/BD
6.BP,PR,GRBS CHARTING 4TH HOURLY,TEMP 2ND HOURLY
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