80 year old with pyrexia of unknown origin ? Pulmonary kochs

 This is an 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 global online community of experts with an aim to solve those patient's 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 the comment box is welcome."I've 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 a diagnosis and treatment plan

80 year old female presented with the complains of fever since 3 months,

burning micturition since 3 months,

difficulty in swallowing since 1 month 


HISTORY OF PRESENT ILLNESS

Patient was apparently assymptomatic 3 months back then developed fever on and off associated with burning micturition & abdominal pain for which she was brought to the hospital and was admitted (pyrexia of unknown origin) and was discharged on 25/10/22 post which she had no complaints till  19/11/22 , when patient had similar complaints and was treated at local hospital 


Previous hospital administration of patient 


https://nehareddygaddam.blogspot.com/2022/10/72-female-with-fever-burning.html?m=1


 

On 10/12/22 patient presented to our hospital with complaints of fever since 20 days associated with burning micturition 

Fever is low grade and continuous associated with chills & rigors , relieved partially with medication


K/c/o DM :20years on TAB.cinod T 

HTN :on Inj.HAI 8u-x-6u


Surgery: Right PFN 11yrs ago


PERSONAL HISTORY:

Decreased appetite takes mixed diet, irregular bowels( Type 1 Bristol stool) ,normal micturition , no allergies 


 Menstrual history:

Age of menarche - 15yrs

LMP- post menopausal status

OBSTETRIC HISTORY:

Age at marriage-12yrs

Gravida 3 (all 3 are Full term NVD)

1st male , 2nd female - died

3rd - female alive 


GENERAL PHYSICAL EXAMINATION 

Patient conscious coherent cooperative 

Moderately built and nourished

Pallor present

No, icterus, cyanosis, clubbing, lymphadenopathy 

Pedal edema upto lower end of tibia 

 Vitals

Bp:150/90mmhg

RR-20cpm

PR-98bpm

SPO2-94%

GRBS-343mg/dl (inj. HAI 14 units given)

TEMP-98.3F

Respiratory system examination 

Inspection

Drooping of right shoulder 

No engorged veins , discharging sinuses , scars

Apex beat cannot be seen

Trachea appears to be central  


Palpation

Inspectory findings are confirmed 

Trachea central

Decreased movements on right side 

Vocal fremitus more on right side 

Tactile fremitus more on right side 


Percussion

Dull note on right side


Auscultation

Inspiratory crepts in the right inframammary area 

Rest of the lung fields normal vesicular breath sounds 


CVS: S1 , S2 present

Pansystolic murmur present

CNS: NAD 

P/A: SOFT NON TENDER 



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