55yr male came with generalised weakness fever and dry cough

CHEIF COMPLAINTS 

55yr male Tiles construction worker came with complaint of generalised weakness ,fever and dry cough since 2 months

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2months back then he had insidious onset of fever, intermittent, relived on taking medications,not associated with chills and rigors.

Fever is associated with generalised weakness(not able to perform his previous routine job works) and dry cough(which is insidious onset, intermittent,relived on taking medication, no aggravating factors, not associated with positional or seasonal variation)

History of weight loss, loss of appetite present.

PAST HISTORY

History of pulmonary tuberculosis 25years back,used ATT for 6months

No DM/HTN/CAD/CVA/EPILEPSY/Thyroid disorder

PERSONAL HISTORY

Married

Mixed diet

Adequate sleep

Appetite decreased from past two months 

Normal micturation 

Regular bowel and bladder movement 

Takes alcohol per day for past 30years

Tobacco for 30years

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION

Patient is conscious, coherent,co-operative

Moderately built and nourished

No Pallor,Icterus,Cyanosis,Clubbing,Lymphadenopathy,Pedal edema

VITALS :-

PR:-84bpm

BP-110/80mmhg

RR-28/min

Temperature


SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

  Inspection :

-Trachea appears to be in centre

-No scars, sinuses,dilated veins over the chest

-Chest-Bilaterally symmetrical

-Chest movement Decreased on right side

Apex beat--1.5cm medial to mid clavicular line in the left 5th intercostal space

-Respiratory movements --decreased on right side with respiration

Chest Measurements :

       Anteroposterior diameter-18cm

               Transverse diameter-28cm

     Ratio of AP diameter : Transverse

Vocal fremitus : Increased on right side of chest

Supraclavicular & Infraclavicular : Bronchial breath sounds

Vocal Resonance:increased on right side of chest

CARDIOVASCULAR:

-Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

PER ABDOMEN :

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no rigidity, no organomegaly

-Bowel sounds heard


Sputum for AFB & CBNAAT : Negative



                                            

Comments

Post a Comment

Popular posts from this blog

75yr old male came with pain over abdomen since 15 days

Image
18/6/33 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. CHIEF COMPLAINTS A 75 year old male, farmer came to OPD with chief complaints of swelling over the abdomen since 5 years and pain over the swelling since 15 days. HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 5 years ago and then he noticed a swelling over his epigastric region, insidious in onset, size of a peanut which gradually progressed to the present size like lemon . It was slightly reducible to lying down. No aggravating and relieving factors. Pati...
Read more

45 yr old lady with dengue- thrombocytopenia

Image
 August 21, 2022 Hi, I am Shaik Ayesha , 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.” I've 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 a diagnosis and treatment plan.  CHIEF COMPLAINTS :  Patient was suffering with fever, chills, headache and generalised body pains since 10 days an...
Read more

a 50yr old farmer came with cough with blood

Image
Hi, I am shaik ayesha 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.” 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 a diagnosis and treatment plan.  CHIEF COMPLAINTS A 50yr male patient farmer by occupation came with cheif complaints of cough since 4 days and fever since 3 days  HOPI ...
Read more