1801006139 - Short case

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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

Case history

41 year old male who works as ward boy in the hospital came with the chief complaints of

-fever since 15 days

-body pains and generalized weakness since 10 days

-loss of appetite since 1week

History of presenting illness

Patient was apparently asymptomatic 15 days back then developed

-fever since 15 days ,low grade , not associated with chills and rigors , no aggravating factors and relieved with medications. Patient went to local doctor and took medications and 2 injections.Body pains and generalized weakness since 10 days

Loss of appetite present since 1week

No history of vomitings ,loose stools,giddiness,cough ,cold,SOB,

H/o easy fatiguability present

No h/o pain abdomen

Past history

N/K/C/O Hypertension,Diabetes Mellitus , Coronary Artery Disease, thyroid , asthma, epilepsy.

H/O umbilical hernia surgery 2 years back .

Personal history

Occupation-ward boy

Appetite -decreased since 1week

Diet -vegetarian

Bowels and bladder movements - regular

Micturition - normal

No allergies

Occasional alcoholic -drinks once/twice monthly-1quarter

General Physical Examination

Patient is conscious, coherent, co-operative ,well-oriented to time ,place and person.

Pallor- present

Icterus -absent

Cyanosis - absent

Clubbing-absent

lymphadenopathy-absent

Edema -absent

Vitals

Temperature-96.8 F

Pulse Rate- 92 beats per minute , Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate -18 cpm

Sp02-98 % on Radial artery

GRBS-103 mg/dl

PALLOR

Systemic examination

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection -

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

Palpation -

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

Auscultation -

Mitral Area - First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area - First and Second Heart Sounds Heard, No other sounds are heard
Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard
Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard

RESPIRATORY SYSTEM EXAMINATION

Inspection -

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

Palpation -

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

Percussion -

Percussion Right                   Left
Supra clavicular: resonant resonant
Infra clavicular:          resonant resonant
Mammary: resonant resonant
Axillary: resonant    resonant
Infra axillary: resonant    resonant
Supra scapular: resonant            resonant
Infra scapular: resonant resonant
Inter scapular: resonant resonant

No tenderness

Auscultation -

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary: NVBS NVBS
Axillary: NVBS                 NVBS
Infra axillary: NVBS         NVBS
Supra scapular:   NVBS NVBS
Infra scapular: NVBS               NVBS
Inter scapular: NVBS               NVBS

No added sounds

PERABDOMEN:

INSPECTION

Umbilicus is central in position

A visible scar due to surgery near the umbilicus.

PALPATION -

No Tenderness on superficial palpation.

Temperature - Afebrile

Liver is Non Tender and not palpable

Spleen is Not palpable

PERCUSSION:Fluid thrill absent

AUSCULTATION- Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM EXAMINATION:

HIGHER MENTAL FUNCTIONS:

Conscious

Well Orientation to time, place and person

Speech and language – normal

Memory – immediate-retention and recall, recent and remote are present

2.CRANIAL NERVES - left Right
Normal normal

3.MOTOR SYSTEM-

      Bulk
Inspection                                normal     normal
Palpation                                normal       normal
Measurement

Upper limb – 10cm below acromion ( same on both )
Lower limb 18 cm below tibial tubercle (same on both)

Tone

Upperlimb                                           Normal         Normal
Lowerlimb                                           Normal        Normal

Power

a. Neck muscles                                Good             Good

b. Upper limbs

i) Shoulder                                           5/5                5/5
Flexion-Extension
Lateral Rotation-Medial Rotation     5/5                5/5
Abduction -Adduction                        5/5                 5/5
ii) Elbow
Flexion-Extension                               5/5                5/5
iii) Wrist
Dorsi flexion-Palmar flexion              5/5                5/5
Abduction-Adduction                         5/5                 5/5
Pronation-Supination                         5/5                 5/5
iv) small muscles of hand               Good              Good
v) Hand grip                                      Good              Good

c. Lower limbs
i) Hip                                                     5/5                5/5
Flexion-Extension
Abduction-Adduction                          5/5                5/5
Lateral Rotation-Medial Rotation       5/5                5/5

ii) Knee
Flexion-Extension                                 5/5                5/5
iii) Ankle
Dorsi flexion-Plantar flexion                5/5               5/5
Inversion-Eversion                                5/5               5/5
iv) Small muscles of foot                   Good           Good

REFLEXES

SUPERFICIAL REFLEXES
A.Corneal reflex                                 Present
B.Conjunctival reflex                         Present
C.Abdominal reflex                           Present
D.Plantar reflex                                  Present

DEEP REFLEXES
A.Biceps                          +2            +2
B.Triceps
                                          +2            +2
C.Supinator
                                   +2                  +2
D.Knee jerk
                                     +2                  +2
E.Ankle jerk
                                     +2                  +2

SENSORY SYSTEM - Normal
CEREBELLAR SIGNS- Absent

SIGNS OF MENINGEAL IRRITATION