32 year old male patient came with fever,abdominal pain&burning micturition
A 32 year old male patient named ashok kumar came to opd with complaints of
Hemogram:
Chief complaints:
- Fever since 7 days
- Abdominal pain since 7 days
-Burning micturition since 3 days
History of presenting illness:
Pt was apparently asymptomatic 7 days back
then he had fever which is sudden in onset,
high grade,also chills and rigor which are relieved on medication.
Pain in abdomen since 7 days mainly in hypchondrium,rt lumbar ,umbilical region,
needle pricking type of pain,aggregated on taking inspiration
H/o burning micturition since 3 days,no urgency , frequency, hesitancy.
No chest pain,sob, palpitations
No nausea, vomiting
No loose stools
No increased or decreased output
History of past illness:
No history of HTN,DM,TB, Asthma, epilepsy, CAD
Family history:
Not significant
Personal history:
He had a surgery at the age of 10 years
Diet - mixed
Appetite - normal
sleep - not complete due to pain
Bowel and Bladder movements- Regular
Addictions - twice a week ,90ml each time
Brandy
No known allergies
Drug history :
No significant drug history
General examination:
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person at the time of examination
He is examined in a well lit room, with consent taken.
He is moderately built and moderatly nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Vitals : on the day of admission (12/4/2023)
Temperature - 101F
Pulse rate - 72 bpm
Respiratory rate - 20 cpm
Blood pressure - 130/90 mmHg
SpO2 - 99% on Room air
GRBS - 121 mg/dl
Systemic examination:-
Abdomen:
On inspection-
Shape of abdomen is scaphoid and no scars. Umbilicus is inverted.
Flanks are free
Normal movements and no visible pulsations.
Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.
No visible veins.
No engorged veins.
no visible gaatric peristalsis
On palpation-
Liver examination:
On superficial palpation
no tenderness , raised temperature
On deep palpation
No tenderness in liver
Non pulsatile
Spleen examination:
No tenderness and pain
Percussion :
No fluid thrill.
No shifting dullness.
Percussion of Liver for Liver Span : 13cm
Auscultation
Normal bowel sounds heard.
2. Bruit - no renal artery bruit heard.
no iliac artery bruit heard.
Respiratory system examination :
Inspection :
Position of trachea central
Slight dropping of right shoulder
No intercostal indrawing
No supraclavicular hallowness
Shape and symmetry of the chest normal.
No dilated veins.
No visible scars.
accessory muscles of respiration not prominent.
Palpation :
On three finger test : position of the trachea central.
Respiratory movements are decreased on right side.
Measurement of left and right hemithorax :
47cm equal on bothsides.
Antero posterior diameter :23cm
Transverse diameter at the level of nipples :31.5cm
AP/transverse diameter ratio = 5.75/7.87.
Distance between vertebrae and infrascapular angle on right and left side is same =13.5cm.
Vocal framitus :. Right. left
Supraclavicular area. Reduced. N
Infraclavicular area. Reduced. N
Mammary area. Reduced. N
Axillary area Reduced. N
Infraxillary area Reduced. N
Suprascapular area. Reduced. N
Interscapular area. Reduced. N
Infrascapular area. Reduced. N
Percussion :
On direct percussion in clavicular area
On right side :
On left side :
Tidal percussion: dullness in the right 5 th intercostal space even after deep inspiration.
Traubes space percussion : dull note
Ascultation :
Vocal resonence :
Right left
Supraclavicular area. Reduced. N
Infraclavicular area. Reduced. N
Mammary area. Reduced. N
Axillary area Reduced. N
Infraxillary area Reduced. N
Suprascapular area. Reduced. N
Interscapular area. Reduced. N
Infrascapular area. Reduced. N
Decreased vesicular breath sounds on right side.
Bilateral air entry positive.
No crackles heard.
CVS Examination :
Inspection :
No abnormal palsations
No visible scars.
No chest deformities.
Mediastinum normal
Trachea central in position.
Palpation :
Mediastinal position : apex beat normal
Position of trachea central.
Percussion :
On percussion No cardiomegaly.
Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.
CNS : NAD
Investigations:-
USG:
Hemogram:
ECG:
Provisional diagnosis:
right side plural effusion with lung collapse.
Tubercular pleuritis
Treatment:-
T.PAN 40MG PO/OD
T.PCM 650 MG PO/TID
INJ.NEOMOL 1MG IV/ SOS
IV FLUIDS NS @50ML/HR
T.MYORIL 4MG PO/SOS
INJ.TRAMADOL 1 AMP IN100 ML NS/TID
MONITOR VITALS.
SOAP notes
S
pain decreased
Fever spikes present
O
Patient is c/c/c
Temp:-100.6° F
PR- 82 bpm
RR-16 cpm
BP- 120/80mmHg
Spo2-100% at room Air
CVS- S1s2present, no murmurs heard
RS-B/L air entry present
N vesicular breath sounds
PA- soft,non tender
CNS - NFND
A
Pain abdomen under evaluation ? pleuritis
Dyselectrolytemia (resolved)
Right moderate Pleural effusion with underlying collapse and consolidation
Mild hepatosplenomegaly
P
IV FLUIDS NS @50ML/HR
INJ.NEOMOL 1GM IV /SOS IF TEMP >101 F
T.PCM 650 MG PO TID
INJ.TRAMADOL 1 AMP IN 100ML NS SOS
T.MYORIL 4MG PO/BD
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