A 65 year old male with sob and fever
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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 resident of mallepalli, nalgonda farmer by occupation came with chief complaints of
Sob since 2 months
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 no progresion, grade 1 not associated with orthopnea, no diurnal or seasonal variations of Sob
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 . History of weight loss present since 1 month.
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 occasionally
He smokes chutta every day since 40 years
DAILY ROUTINE
Patient is farmer by occupation he stopped working 7 years back because of old age
He wakes daily at 6am ,goes to bathroom fresh up and takes bath and drinks tea at 7 am From 7 am to 9 am he sits simply at home
has rice and curry for breakfast at 9 am From 9 am to 2pm he just goes out for a walk to neighbors house he eats his lunch at 2pm he sleeps for 2 to 2and half hours again he takes tea at 6pm and dinner at 8pm and sleeps by 9 30 pm.
GENERAL EXAMINATION
patient is conscious,coherent and cooperative
well oriented to time,place and person
thin built and poorly 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
INSPECTION:
Upper Respiratory tract:
Nose- no polyps, dns
oral cavity- poor oral hygiene
Post pharyngeal wall- normal
LRT
Inspection
Shape of chest : bilateral symmetrical,elliptical
trachea: central
supraclavicular hollowness present
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 mid clavicular line
Tactile Vocal fremitus increased at right Infraclavicualr area, Mammary area
Diameters
Anterioposterior: 21cm
Transverse: 22 cm
Chest circumference: inspiration: 79 cm
Expiration:75 cm
PERCUSSION:
Dull in right infraclavicular and mammary area
AUSCULTATION:
BAE+
Normal vesicular breath sounds heard except in the right infra clavicular and mammary area
Bronchial breath sounds at right infra clavicular area
Vocal resonance increased in right infraclavicular and mammary area
Clinical images:
INVESTIGATIONS:
Echo:
PROVISIONAL DIAGNOSIS
Right upper lobe and middle lobe non homogenous opacities are seen may be 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
on 29/12/22
added tab nodosis 500 mg PO BD
protein powder in milk PO BD
on 30 and 31/12/22
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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