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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.
Chief complaints:
Fever since 7 days
Pain abdomen since 7 days
Burning micturition since 3 days
History of present illness:
Patient was apparently alright 7 days back then he had fever which is sudden in onset, high grade, with evening rise in temperature associated with chills and rigors, associated with night sweats releived by taking medication.
No H/o headache , no H/o body pains, no H/o retro orbital pain
pain abdomen since 7 days in right hypochondriac ,right lumbar, umbilical region, needle pricking type of pain , non-radiating and aggrevated during inspiration and on turning over on the bed.
No H/o nausea , no H/o vomiting , no H/o sob , no H/o loose stools, no H/o constipation, no H/o blood in stools or dark coloured stools.
H/o burning micturition since 3 days,no urgency , frequency, hesitancy.
No increased or decreased output
Past history
Not k/c/o HTN,DM,TB, EPILEPSY,CVA
Family history:- not significant
Personal history:
Appetite:- normal
Diet:- mixed
Sleep :- adequate
B& B :- regular
No addictions
Patient is conscious, coherent, cooperative well oriented to time place and person .
Moderately built, moderately nourished
Pallor:- absent
Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Generalized lymphadenopathy:- absent
Bilateral pedal edema :- absent
Vitals:-
Bp:120/80 mmhg
Pulse rate:-80 bpm
RR:- 18 cycles per min
Temp :-
Systemic examination:-
ABDOMEN EXAMINATION :
Inspection:
Shape of abdomen scaphoid
Umbilicus inverted
No scars sinuses engorged veins
No visible peristatlsis
No visible pulsations
Palpation:
Local Rise of temperature present.
Tenderness in right hypochondrium ,right lumbar,umbilical region
Liver and spleen non palpable .
Percussion:
Liver span: 8cm
No shifting dullness
No fluid thrill
Auscultation: bowels sounds (8/min) were heard
Respiratory system:
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appears normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and its Abdominothoracic type.
Trachea central in position & Nipples are in 4th Intercoastal space
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations.
Palpation:-
All inspiratory findings confirmed
Trachea central in position
MEASUREMENTS-
AP diameter- 8 inch
Transverse diameter- 12 inches
AP/T ratio - 0.66
Respiratory movement's:- normal on both sides
Tactile vocal fremitus - increased in Infraaxillary & infra scapular area.
Percussion:-
Right left
Supraclavicular- Resonant (R) (R)
Infraclavicular- (R) (R)
Mammary- (R)
Dull
Infra mammary- dull (R)
Axillary-
(R) (R)
Infra axillary- (R)
(R)
Suprascapular- (R) (R)
Interscapular- (R) (R)
Infrascapular- Dull dull
Auscultation:-
Right Left
Supraclavicular- Normal vesicular NVBS
Breath sounds (NVBS)
Infraclavicular- NVBS NVBS
Mammary-
Reduced breath sounds NVBS
Axillary- NVBS NVBS
Infra axillary- NVBS NVBS
Suprascapular- NVBS NVBS
Interscapular- NVBS NVBS
Infrascapular- NVBS NVBS
CVS :
Inspection:
No chest wall abnormalities
No scars sinuses sinuses engorged veins
Trachea appears to be central
Apical impulse not visible
Palpation:
Apical impulse felt at 5th ics 1cm medial to midclavicular line
No parasternal heaves
No thrills
Auscultation:
Cvs :- s1,s2 heard no murmurs
Cns :- no focal neurological deficits
Investigations:-
x - ray :-
USG
Ecg
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