60F with fever , vomitings and productive cough
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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.
CHEIF COMPLAINTS
Patient came to opd with fever since 10 days,vomitings since 10 days,cough since 10 days
HOPI
Patient was apparently asymptomatic 10 days ago.She then developed fever, vomitings and cough.Fever was low grade,intermittent,not associated with chills and rigors.2-3 episodes of vomitings per day which is watery,non projectile,non blood tinged with food particles as contents.Cough is associated with whitish mucoid sputum,not blood days.Pain in the back while coughing. History of constipation and decreased appetite since 10 days.
PAST HISTORY
Not a k/c/o DM,HTN,Tb, Asthma,Epilepsy,CVA,CAD,Thyroid
Surgical history: Tubectomy 35yrs ago. Cataract Rt eye 5 yrs back Lt eye 3 yrs back
PERSONAL HISTORY
Diet- mixed
Appetite- decreased since 10 days
Bowel and bladder-constipation since 10 days
Sleep- regular
Addictions- none
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient is conscious,coherant,and cooperative.
Pallor present
No signs of icterus,clubbing,cyanosis,
lymphadenopathy,edema.
Palpation-
TEMP: 100.6F
BP: 100/70mmHg
PR: 112 bpm
RR- 16cpm
Spo2- 98% @RA
Systemic Examination:
CVS: Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscaltation-
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS
Patient is conscious ,coherent and co operative , well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
ABDOMEN
On inspection:
All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars, engorged veins ,sinuses.
Palpation- No Local rise in temperature and no tenderness
On percussion::
Tympanic note - heard
On auscaltation::
Bowel sounds heard
Provisional Diagnosis-
PYREXIA UNDER EVALUATION
INVESTIGATION:
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