50 year old male with fever and yellow discoloration of eyes since 1 month

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available 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 centered online learning portfolio and your valuable comments in comment box are most welcomed.

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 to come up with a diagnosis and treatment plan.

A 50 years old male, tiles repair worker by occupation and resident of Bhongir , presented with chief complaints of fever since 2 months, loss of appetite since 2 months, pain in abdomen 20 days back and yellowish discoloration of eyes since 20 days.

History of presenting illness

Patient was apparently asymptomatic 2 months back , then he developed fever which was insidious in onset, intermittent in nature, low grade with no rigors and chills, no aggrevating and relieving factors.

Now, since 20 days, his fever usually spikes at evening which would continue the whole night, and reduce by morning, and is associated with chills.

Fever was not associated with nausea, vomitings, headache and constipation.

He also lost his appetite gradually since 2 months, which increased more 20 days back, with history of weight loss since 20 days.

Patient had decreased appetite since 2 months associated with nausea while eating, which resolved over time.

His appetite decreased further and he didn't eat rice since 3 days, and now since 2 days his appetite increased a little again.

Patient also complained of pain in abdomen in the umbilical and right lumbar region, which was insidious in onset, gradually progressive, non radiating, aggravated while walking (around 100 metres)  and relieved on rest.

Now he doesn't have any pain.

He had sensation of burning while micturition, not a/w urgency, frequency, incontinence, polyuria, polydipsia, nocturia, urethral discharge.

Then later he had decreased appetite, weight loss and fever for which he came to kamineni.

No history of itching.

No history of flatulence, bloating

No H/o pedal edema, SOB, chest palpitations, chest pain and tightness. 

Patient was diagnosed HIV positive 3 days back.

Past History 

Patient is known case of pulmonary tuberculosis 25 years ago, for which he used medication for 6 months.

Not a known case of DM, HTN, CVA, CAD, thyroid disorders, asthma and epilepsy.

Personal history 

Daily routine

Patient wakes up at 5 am, goes for a walk to get milk, and returns home. He then has tea with biscuits and rice for breakfast, then leaves for his work by 9 am.

He has rice, for lunch, with curries at his workplace.

He comes back from work at either 7 or 8 pm.

He has rice for dinner at 9 pm and goes to sleep by 10 pm.

Diet - mixed 

Appetite - decreased since 2 month 

Bowel - irregular , once 3 days and watery in consistency since 10 days , resolved now.

Bladder - burning micturition since 20 days.

Sleep - adequate 

Addictions - 90 ml occassionally since 35 years.

Family history 

No similar complaints 

Surgical history 

Appendicectomy done 30 years ago

General examination 

Examination was done in well lighted room, with consent and informing the patient in the presence of a female attendant.

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

Pallor - present 

Icterus- absent 

Cyanosis- absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - absent

Vitals 

Temperature- 38⁰ C 

PR - 105bpm

RR - 23 CPM 

BP - 100/60 mmhg

SpO2 - 99% at RA

GRBS - 114mg/dl

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

Patient examined in sitting position 

Inspection 

Lips and tongue no Cyanosis 

Oral candida - absent

Poor oral hygiene

Trachea- centralized 

Nipples - at 5th inter costal space

Shape - elliptical, B/L symmetrical 

Symmetrical Chest movement

Respiratory movements appear equal on both sides and abdominothoracic type

No scars, sinuses and dilated veins.

No lumps and Lesions 

No intercostal recession  

Palpation

no local rise in temperature  

No crowding ribs 

No tenderness 

No swelling 

Apical impulse felt at 5th intercostal space and at mid clavicular line

Chest expansion - 

Measurements - 

Total circumference - 34 inches 

Hemithorax , Right - 17 inches Left - 17 inches 

Anterior - Posterior - 8 inches 

Transverse - 12 inches

Tactile vocal fermitus -   Right.      Left

Supraclavicular -.  Increased.   Normal

Infraclavicular-  increased.     Normal

Mammary- increased           normal

Axillary-  normal.           Normal

Infra axillary-  normal.         Normal          

Suprascapular- normal.      Normal

Interscapular- normal.       Normal

Infrascapular- normal.      Normal

Percussion

Resonant in all regions  

Auscultation

Fine creptitations heard at infraclavicular area.

Normal vesicular breath sounds in other areas.

ABDOMINAL EXAMINATION 

Inspection 

Shape - scaphoid 

Umbilicus- centralized, inverted 

Scar present of appendicectomy 

No dilated veins 

No visible gastric and intestinal peristalsis

No Hernial orifices 

Palpation 

Superficial palpitation - tenderness present 

Deep palpation- 

Liver - 

Non tender, no swelling present 

Not palpable

Spleen- not palpable

Kidney - not palpable

Percussion 

No fluid thrill

Percussion Liver span 

Percussion of Spleen span

Auscultation 

No bowel sounds heard

CVS EXAMINATION 

Inspection 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation 

Apex beat can be palpable in 5th intercostal space

Auscultation 

S1,S2 are heard

no murmurs

CNS EXAMINATION 

Higher mental functions :intact

Cranial nerves intact

Motor examination: R L

Bulk. N N

Tone. N N

Power. N N

Reflexes:

Biceps. 2+ 2+

Triceps. 2+ 2+

Supinator 2+. 2+

Knee 2+.2+.

Ankle. 2+. 2+

Sensory examination:Normal

No meningeal signs

Provisional diagnosis - pyrexia with jaundice 

Anemia?

HIV positive 

Investigations

On 12/6/23

On 13/6/23

On 14/6/23

On 15/6/23

Diagnosis

PYREXIA UNDER EVALUATION

K/C/O PULMONARY TB 25YRS AGO

RVD POSITIVE

Treatment

1.IV FLUIDS@75ML/HR

2.INJ NEOMOL 1GM IV SOS

3. TAB OROFER XT

4.INJ MONOCEF 1GM IV/BD

5.TAB PCM 650MG PO/BD

5.BP,PR,GRBS CHARTING 4TH HOURLY,TEMP 2ND HOURLY