A 39 year old male with cough 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. 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.

CHIEF COMPLAINTS :

Cough since 1 week

Fever since 1 week

HISTORY OF PRESENTING ILLNESS:

-Patient was apparently asymptomatic 1 week back then he developed cough which was initially associated with sputum,which was greenish in color later it became non productive,which was intially insidious in onset,gradually progressive and not associated with any aggravating or relieving factors.

-No h/o breathlessness,chest pain,hemoptysis, palpitations,indigestion,weight loss,night sweats.

-He also developed fever 1 week back which was insidious in onset, gradually progressive, intermittent,low grade and there is evening rise of temperature,it subsided with medication.

-He also complained of generalised weakness and insomnia.

PAST HISTORY:

Similar complaints one month back 

h/o diabetes mellitus since 7years and uses metformin

No h/o hypertension,asthma,epilepsy, coronary artery disease.

FAMILY HISTORY:

No similar complaints in the family 

PERSONAL HISTORY:

Sleep - not adequate

Appetite - decreased

Bowel and bladder movements - regular

Addictions - habit of chewing khaini since 20 yrs but stopped it from past 20 days

Drinks alcohol weekly once from past 10 yrs but stopped since 3 yrs

GENERAL EXAMINATION

Patient is conscious,coherent,cooperative and

he is malnourished.

Pallor - absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

VITALS:

RR-16cpm

BP-130/90mmHg

PR-82bpm

SpO2-98%

Temperature-afebrile

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM:

URT -

Nose is normal

No polyp,DNS,pharyngeal congestion

LRT -

INSPECTION:

Chest is symmetrical

Movements of chest - symmetrical

Respiratory movements - rate:16cpm

                                  Type: abdominothoracic

Trachea appears to be central

No drooping of shoulders, intercostal fullness or retraction,crowding of ribs,winging of scapula

No visible sinuses,scars,dilated veins

PALPATION:

No local rise in temperature and no tenderness

Expansion of chest is equal on both sides in anterior,posterior and apical areas.

Trachea is central in position

Apex beat is felt in left 5th ICS 

TVF-vibrations decreased in mammary,axillary and interscapular areas

PERCUSSION:

Direct-Resonant

Indirect-dull at left interscapular and interaxillary areas

AUSCULTATION:

Breath sounds decreased at left axillary,mammary and interscapular areas.

CVS:

S1 and S2 heard 

No murmurs

CNS:

No focal neurological deficits

Per abdomen:

Soft and non tender

No organomegaly

PROVISIONAL DIAGNOSIS:

Left pleural effusion 

INVESTIGATIONS:

XRAY chest:

USG chest:

TREATMENT:

T Cefixime 200mg PO BD

T PAN D 40mg PO OD 

Syrup Grillinctus D 2tsp PO BD

T UDILIV 300mg PO BD