50 year old with fever , abdomen pain and RVD +ve
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A 50 years old male , tile repairing man by occupation and resident of Bhongir , presented with
cheif complaints of Fever since 2 months , loss of appetite since 2 months
pain in abdomen 20 days back
yellow discoloration of sclera since 20 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 months back , then he developed fever which was insidious in onset , Intermittent in nature , it was low grade with no rigors and chills , patient had fever whenever he worked , his fever usually spikes at evening which would continue till 3-4 days , Then he would take herbal medicine ( ayurvedic) herbal medicine to reduce it . This is been continuing since 2 months . Fever was not associated with nausea , Vomitings headache and constipation. No h/o itching He also lost his appetite gradually since 2 months, the amount of rice had reduced compared to his meals before 2 months which increased more 20 days back .Then he had pain in abdomen in the umbilical and right lumbar region ,which was insidious in onset ,gradually progressive, non radiating, aggravated while walking and no relieving factors .He had sensation of burning while micturition, not a/w urgency to urinate frequency, incontinence, polyuria, nocturnal, urethral discharge. Due to retained yellow discoloration since 1 month to which he consulted RMP doctor and there he was diagnosed to have jaundice . There is history of weight loss since 20 days .
No history of flatulence , bloating
No H/o pedal edema, SOB , chest palpitations, chest pain and tightness .
He Was diagnosed HIV positive 3 days back.
Past History
Patient is known case of pulmonary tuberculosis 25 years ago , for which he used medication for 6 months .
Not a known case of DM , HTN , CVA, CAD , Thyroid disorders , asthma and epilepsy.
Personal history
Daily routine
5 am -waking up
7:30 am - has his tea with biscuits
9:00 am - goes to work
1 pm - lunch
5:30 pm comes back from work
8 pm dinner
9:30 pm goes to bed
Diet - takes mixed
Appetite - decreased 2 month
Bowel and bladder- irregular , once 3 days and watery in consistency since 10 days , resolved now .
Addictions -
3 times a week , 90 ml every time ( IB alcohol) since 35 years
Chews tobacco from 35 years .
Family history
No similar complaints
Surgical history
Appendicectomy done 30 years ago
General examination
Examination was done in well lighted room , with consent and informing the patient in the presence of a female attendant .
Patient was conscious , coherent and cooperative, well oriented to time , place and person .
Pallor - present
Icterus- absent
Cyanosis- absent
Clubbing - absent
Lymphadenopathy- absent
VITALS
Temperature- 38⁰ C
PR - 105bpm
RR - 23 CPM
BP - 100/60 mmhg
SpO2 - 99% at RA
GRBS - 114mg/dl
Systemic examination
RESPIRATORY SYSTEM
Patient examined in sitting position
Inspection
Head to Toe examination
Eyes - pallor
Lips and tongue no Cyanosis
Oral candida - absent
Trachea- centralized (trial's sign )
Nipples - at 5th inter costal space
Respiratory movements appear equal on both sides and it's Abdominothoracic type
No scars and sinuses and dilated veins.
Hollow spaces present supraclavicular and infraclavicular
No lumps and Lesions
Shape - elliptical- B/L symmetrical
Symmetrical Chest movements
No intercostal recession
PALPATION
No rise in temperature
No crowding ribs
No tenderness
No swelling
Apical impulse felt at 5th intercostal space and at mid clavicular line
Chest expansion -
Measurements -
Total circumference - 34 inches
Hemithorax , Right - 17 inches Left - 17 inches
Anterior - Posterior - 8 inches
Transverse - 12 inches
Tactile vocal fermitus - normal in all regions
Infraclavicular- (NVBS) (NVBS)
Mammary- (NVBS) (NVBS)
Axillary- (NVBS) (NVBS)
Infra axillary-(NVBS) (NVBS)
Suprascapular- (NVBS) (NVBS)
Interscapular- (NVBS) (NVBS)
Infrascapular- (NVBS)(NVBS
PERCUSSION
Resonant in all regions
AUSCULTATION
Normal vesicular breath sounds
GASTRO INTESTINAL INVESTIGATIONS
INSPECTION
Shape - scaphoid
Umbilicus- centralized, inverted
Scar present of appendicectomy
No dilated veins
No visible gastric and intestinal peristalsis
No Hernial orifices
PALPATION
Superficial palpitation - tenderness present
Deep palpation-
Liver -
NON tender, no swelling present
Not palpable
Spleen- not palpable
Kidney - not palpable
PERCUSSION
NO fluid thrill
Percussion Liver span
Percussion of Spleen span
AUSCULTATION
no bowel sounds heard
CVS EXAMINATION
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
Palpation :
Apex beat can be palpable in 5th intercostal space
Auscultation :
S1,S2 are heard
no murmurs
CNS EXAMINATION
Higher mental functions :intact
Cranial nerves intact
Motor examination: R L
Bulk. N N
Tone. N N
Power. N N
Reflexes:
Biceps. 2+ 2+
Triceps. 2+ 2+
Supinator 2+. 2+
Knee 2+ 2+
Ankle. 2+. 2+
Sensory examination:Normal
No meningeal signs
Provisional diagnosis - pyrexia ? Jaundice ?
Investigations
13/06/2023
Diagnosis
PYREXIA UNDER EVALUATION K/C/O PULMONARY TB 25YRS AGO AND RVD POSITIVE
Treatment
1.IV FLUIDS@75ML/HR
2.INJ NEOMOL 1GM IV SOS
3.INJ MONOCEF 1GM IV/BD
4.TAB PCM 650MG PO/BD
5.BP,PR,GRBS CHARTING 4TH HOURLY,TEMP 2ND HOURLY
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