general medicine case presentation

B. VAISHNAVI
9TH SEM

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

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.


A 65 yr old male construction worker by occupation came with

CHIEF COMPLAINTS:

-Fever and Yellowish discoloration of eyes since 1 month 

-Cough & SOB since 1 month

 -Burning micturition and abdominal pain since 15 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic until 1 month ago then had fever (high grade) with chills which is intermittent, no diurnal variation associated with burning micturition and  dark coloured urine and yellowish discoloration of eyes

H/o vomitings, loss of appetite , generalized weakness, weight loss of 3 kg since 1 month.

Few days later he developed cough which is productive with whitish sputum, thick consistency, mucoid associated SOB grade 2 and wheeze since 1 month aggravated on exposure to cold &dust.

After 15 days he developed abdominal pain and indigestion of food

PAST HISTORY:




Normal chest movements

Vocal fremitus is normal in all areas ( in sitting position)

Percussion: in sitting postion

                                      Rt.                 Lt


Supraclavicular.        N(resonant)    N

Infraclavicular.           N.                     N

Mammary region.      N.                     N

Inframammary region.  N.                 N

Axillary region.              N.                    N

Infra axillary region.     N.                     N

Supra scapular region.  N.                    N

Interscapular region.   N.                       N.  

Infrascapular region.    N.                      N

Auscultation:

Normal vesicular breath sounds

B/l fine crepts present in Mammary and Infra axillary region 

B/l Rhonchi in Intrascapular region,Mammary region


Chest x ray








On 11/11:



Treatment Given:

Inj.Optineuron 1 ampoule in 100 ml ns iv od

Tab.Amoxiclav 625 mg po bd

Tab.Udiliv 150 mg po bd

Syp.Lactulose 15 ml po tid

Neb duolin 6th hrly

Tab.pcm 650 mg po sos



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