60F with fever, vomitings and productive cough.

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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.

CHEIF COMPLAINTS

Patient came to opd with fever since 10 days,vomitings since 10 days,cough since 10 days

HOPI

Patient was apparently asymptomatic 10 days ago.She then developed fever, vomitings and cough.Fever was low grade,intermittent,not associated with chills and rigors.2-3 episodes of vomitings per day which is watery,non projectile,non blood tinged with food particles as contents.Cough is associated with whitish mucoid sputum,not blood days.Pain in the back while coughing. History of constipation and decreased appetite since 10 days.

PAST HISTORY

Not a k/c/o DM,HTN,Tb, Asthma,Epilepsy,CVA,CAD,Thyroid

Surgical history:                                                Tubectomy 35yrs ago.                                     Cataract Rt eye 5 yrs back Lt eye 3 yrs       back

PERSONAL HISTORY

Diet- mixed

Appetite- decreased since 10 days

Bowel and bladder-constipation since 10 days

Sleep- regular

Addictions- none

FAMILY HISTORY 

Not significant

GENERAL EXAMINATION 

Patient is conscious,coherant,and cooperative.

Pallor present

No signs of icterus,clubbing,cyanosis,

lymphadenopathy,edema.

Palpation-

TEMP: 100.6F

BP: 100/70mmHg

PR: 112 bpm

RR- 16cpm

Spo2- 98% @RA

Systemic Examination:

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation-

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CNS

Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact 

ABDOMEN

On inspection:

All quadrants are moving equally with respiration

Umbilicus - central and inverted

No scars, engorged veins ,sinuses.

Palpation- No Local rise in temperature and no tenderness

On percussion::

Tympanic note - heard 

On auscaltation::

Bowel sounds heard 

Provisional Diagnosis- 

PYREXIA UNDER EVALUATION

INVEATIGATIONS