65 yr male with fever, and vomitings

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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.

UNIT 1

DOA: 5/6/23 

Chief complaints- 

C/o fever since 15 days 

C/o vomitings since 15 days

C/o generalised body pains since 15 days 

C/o pain during swallowing since 15 days 

HOPI- 

Patient was apparently asymptomatic 15 days back then developed fever, insidious in onset, gradually progressive, high grade, intermittent associated with chills and rigours associated with generalised body pains 

C/o vomitings- 1 episode, bilious, food as content non blood stained, non projectile. 

H/o burning micturition 15 days back 

No dysuria, frequency, urgency, hesitancy 

H/o pedal edema 15days back along with decreased urine output for which he was treated in hospital and was treated with antibiotics (piptaz for 5 days) following which both are resolved 

PAST HISTORY- 

Not a k/c/o TB,DM,HTN,ASTHMA, CVD,CAD 

PERSONEL HISTORY: 

Diet:mixed

Sleep:regular 

No loss of Appetite

Bowel movements are regular 

No Addictions

Family history- insignificant 

General examination::

Patient is conscious,cohorent , cooperative well known with time, place, person 

He is well built and moderately nourish

Pallor- Absent 

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 

VITALS:

TEMP:97.1F

PR- 86bpm

RR:18cpm

BP:120/80mm hg

Spo2: 98GRBR.A

GRBS:125mg/dl

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (NVBS)

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (NVBS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs

PER ABDOMEN- 

**Shape of abdomen-Obese

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - Not palpable

**Bowel sounds - Normal

Provisional Diagnosis- left pyelonephritis 

INVESTIGATIONS-

Treatment- 

Inj neomol  1gm IV/SOS

Inj piptaz 4.5gm iv TID

Tab Pan 40mg po/od

Tab Pcm 650mg PO/TID 

Betadine gargles BD