19 Year old male with fever and lower backache
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 19 year old male who is a intermediate second year student resident of miryalaguda came to general medicine OPD with chief complaints of
Fever since 3 days
Lower back ache since 3 days
Abdominal pain since 3 days
And Generalized weakness
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 days back then he developed high grade fever which was insidious in onset, gradually progressive and continuous not associated with chills and rigor and there is no diurnal variation.
He also complained of low back ache since 3 days which is insidious in onset ,gradually progressive, and is persistent and pain increased during inspiration and no relieving factors.
He also complained of abdominal pain which is insidious in onset, diffuse type, persistent not associated with nausea and vomiting.
He also complained of generalized weakness since 3 days.
He had one episode of vomiting 2 days back which was non projectile and contained food particles.
No h/o burning micturition, increased frequency of urine, difficulty to pass urine.
No h/o loose stools.
DAILY ROUTINE
He wakes up at 8 AM and does his morning routine , eats breakfast at 9 AM usually eats 4 idlies or 1 dosa or 4 bondas and goes to college at 9 AM by bus as his college is 20-25 km far from his home ,He is a CEC student attends all his classes and eat lunch at 2PM usually he eats junk foods [fried rice ,noodles,road side foods] almost daily as he feels embarrassed taking lunch box along with him , college ends at 4 PM ,comes back to home by 5 PM and eat dinner at 6 PM ,he usually prefers to eat rice in dinner. After having dinner he watches movies till 12 AM or go out with friends
His parents are agricultural labourer so sometimes he goes along with them Or sometimes he skips college and goes to work along with his cousin brother as part of recreation [ his cousin brother has plastic and iron shop where they store all the plastic and iron which they collected and sell them to others for reuse]
Since 1 month he stopped going to college as his other friends in their village were not going
PAST HISTORY
History of fever 10 days back which was diagnosed as typhoid and was given oral medication for 3 days and iv medication for 1 day
No history of Hypertension, diabetes, asthma, epilepsy,TB
No history of prolonged hospital stay
No history of previous surgeries
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Diet : mixed
Appetite: decreased since 3 days
Bowel and bladder:regular
Sleep:adequate
History of toddy and beer consumption occasionally
TREATMENT HISTORY
Used DOLO 650 mg tid for 3 days
GENERAL EXAMINATION
Patient was conscious ,coherent and cooperative
Moderately build and moderately nourished
well oriented to time ,place and person
SYSTEM EXAMINATION:
Abdominal examination-
INSPECTION
On Inspection Abdomen is flat, no abdominal distension, umbilicus is central and inverted ,no engorged veins,no scars,sinuses,hernial ornifices are clear
PALPATION
All inspectory findings are confirmed
Tenderness present in epigastric region and right hypochondrium region
Tenderness present in right renal angle
Blanching present on Abdomen and back
liver dullness in 5th intercoastal space,
PERCUSSION : No significant findings
AUSCULTATION: bowel sounds heard
RESPIRATORY EXAMINATION
trachea central,
normal respiratory movements,
normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 ,S2 heard ,no murmurs
CNS EXAMINATION
CNS examination
No focal neurological deficits
INVESTIGATIONS
FEVER CHART
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