19 years old male patient with 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.
M. Swathi 8th semester
Roll no 94
This is a case of 19 year old male from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of
CHIEF COMPLAINTS
Fever since 5 days
Lower back ache since 5 days
Generalized weakness since 5 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15days back then he developed high grade fever which was continuous ,no diurnal variation which got relieved on medication given by local RMP
Now again since 5 days he had high grade fever which was continuous not associated with chills and rigor ,no diurnal variati
He also complained of low back ache since 5days which is insidious in onset ,gradually progressive, and is persistent and pain increased during inspiration and no relieving factors
He also complained of abdominal pain which is insidious in onset persistent not associated with nausea and vomiting
He also complained of generalized weakness since 5 days
No history of burning micturition, increased frequency of urine ,difficulty to pass urine ,nocturnal eneursis
No history of loose stools
DAILY ROUTINE
He wakes up at 8 AM and does his morning routine , eats breakfast at 9 AM usually eats 4 idlies or 1 dosa or 4 bondas and goes to college at 9 AM by bus as his college is 20-25 km far from his home ,He is a CEC student attends all his classes and eat lunch at 2PM usually he eats junk foods [fried rice ,noodles,road side foods] almost daily as he feels embarrassed taking lunch box along with him , college ends at 4 PM ,comes back to home by 5 PM and eat dinner at 6 PM ,he usually prefers to eat rice in dinner. After having dinner he watches movies till 12 AM or go out with friends
His parents are agricultural labourer so sometimes he goes along with them Or sometimes he skips college and goes to work along with his cousin brother as part of recreation
PAST HISTORY
No history of Hypertension, diabetes, asthma, epilepsy,TB
PERSONAL HISTORY
Diet : mixed
Appetite: decreased since 5 days
Bowel and bladder:regular
Sleep:adequate
History of toddy and beer consumption occasionally
Family history;
No relevent family history
TREATMENT HISTORY
Used DOLO 650 mg tid for 5 days
GENERAL EXAMINATION
Patient was conscious,coherent cooperative
Moderately build and moderately nourished
well oriented to time ,plapla
Lymphadenopathy: absent
Edema : absents
SYSTEM EXAMINATION:
Abdomin
al examination-
INSPECTION
On Inspection Abdomen is flat, no abdominal distension, umbilicus is central and inverted ,no engorged veins,no scars,sinuses,hernial ornifices are clear
PALPATION
All inspectory findings are confirmed
Tenderness present in epigastric region and right hypochondrium region
Tenderness present in right renal angle
liver dullness in 5th intercoastal space
PERCUSSION : No significant findings
AUSCULTATION: bowel sounds heard
RESPIRATORY EXAMINATION
trachea central,
normal respiratory movements,
normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 ,S2 heard ,no murmurs
CNS EXAMINATION
CNS examination
No focal neurological deficits
INVESTIGATIONS
FEVER CHART
ECHO
On 1 nov 2022
Iv normal saline
Ringerlactose 75ml hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml
Inj piptaz4. 5g /tid
On 2 november 2022
normal saline iv
Ringerlactose 75ml hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 1 gm
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