65 years old patient with fever and suspected pneumonia

With UG learning is coming to be almost there to graduate the new case presented to OPD with complaints of fever

M Bhuvana phanindra, 

9th semister, Roll no.74.

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 centred online learning portfolio and your valuable inputs on comment box is welcome

As a part of "patient clinical data analysis" I was given this case to improve my clinical competence in reading and comprehending along with history taking , clinical findings, and investigations , investigations to come up with a diagnosis .

This is the reflection of my case study:

65 year old female resident of Nalgonda came with chief complaints of fever.

History of Present illness:

.Patient was apparently asymptomatic 4 months back hade a lump removed from chest

. Recurrent fever episodes since then

.New episode of fever came on Thursday with weekends

. Patient got admited to hospital by attendent 

Past history:

. History of hytn, dm since 10+ years

.No history of similar complaints and hospitalization in the past

.No history of Epilepsy , Asthma ,Thyroid 

Family history : 

.Not significant

Personal history:

.Mixed diet

. Appetite, reduced since 1 year.

.Sleep adequate

.Bowel and bladder -Regular

.No known Allergies to any medication or foods

General Physical Examination

.Examination was done with consent, along with female attendent in a well lit closed room exposed over trunk .

.She was conscious ,coherent and cooperative and well oriented to time ,place ,person.

.Thin built and moderately nourished

VITALS

.BP :130/80 mm Hg

.HR: 109 bpm

.RR:18 cpm

.Temperature:103°f , febrile

.Spo2: 100% on room air

pallor +

,no icterus , cyanosis, clubbing ,keilonychia, lymphadenopathy, and edema

Head to toe examination: 

Local Examination:

Inspection :Normal, no scars and sinuses

Palpation :Normal, visual inspectory findings confirmed

Auscultation : Normal ,no crepts or thrills.

Systemic examination:

CVS- S1, S2 heard

RS- B/LAE +

CNS- NFD , no signs of meningial involvement.

P/A- soft

Clinical images:

Investigations:

Provisional diagnosis:

Fever under evaluation with suspension of pneumonia, cerebral involvement,  tuberculous meningitis.

Treatment: