57 YR male with Fever since 1 month

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This E blog 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 diagnosis and treatment plan.

CHIEF COMPLAINTS:

Fever since one month 

HOPI :

Patient was apparently asymptomatic one month back then he developed fever, which is insidious in onset, high-grade, intermittent associated with chills and rigors.Generalised body pains were present.

H/o small swellings since 10 days over bilateral lower limbs and right hand, which is associated with pain and pus point was present.

H/o headache, diffuse type, not associated with photophobia,phonophobia,blurring of vision,Watering of ice.

H/o vomiting since one day associated with nausea, non-projectile, non-bilious non-bloodstained containing food particles as content .

H/o cough since 1 day,dry cough.

No history of abdominal pain, loose stools, constipation.

PAST HISTORY:

K/C/O T2DM , HTN Since 10 years

N/K/C/O Epilesy, Asthma, Thyroid disorders,TB.

PERSONAL HISTORY:

He is a Handloom worker.He wakes up at 5 in the morning,gather things for making sarees and He does his breakfast at 8:00AM . He works till 7 PM .He has his food at 1 PM in afternoon and 8 :00 PM at night , sleeps at 9 PM

DIET :mixed

APPETITE :decreased 

SLEEP: adequate 

BOWEL AND BLADDER :Regular 

H/O Alcohol intake Since 20 Yrs every day about 50 to 100 ml

Stopped since 3 months.

No H/O Tobacco intake

No H/O Allergies

FAMILY HISTORY: 

N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders.

CLINICAL IMAGES:

GENERAL EXAMINATION:

Patient is conscious,coherent and co operative.

Well oriented to time,place and person

No Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema.

VITALS:

TEMP: 104.1F

BP: 110/80 MM/HG

PR: 94 BPM

SPO2: 98% at RA

RR: 18CPM

SYSTEMIC EXAMINATION:

CVS : S1 , S2 heard, no murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits