A 55 years old patient presented with fever, chest pain and loss of appetite
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 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 inputs on the comment box"
55 year old male, farmer by occupation, came to Medicine OPD with complaints of :
Chief complaints
Fever since 13 days , chest pain since 10 days, and loss of appetite since 10 days
History of present illness
Patient was apparently asymptomatic 8 months ago then he developed fever , cough, shortness of breath on exertion
fever is of high grade associated with chills and rigours diurnal variation ,relieved with medication
cough was initially dry cough ten progressed to productive cough with scanty sputum ( white non-bloodstained type) , non foul smelling . The sputum was more produced during night
Patient was evaluated with Bronchoscopy and diagnosed with the right lower lobe aspergilloma and started on itraconazole (200mg) BD for 6 months patient was recovered symptomatically and was well till the last 13 days
13 days ago patient developed fever which was low grade, not associated with chills and rigours .
Chest pain was sudden in onset 10 days ago , pain increased with chest movements associated with SOB grade 2 progressed to grade 3
h/o orthopnea is present
no h/o of PND
Palpitations are present ,excessive sweating is present.
patient was evaluated and found to have LV (left ventricular) strain and tall tented T waves and was treated symptomatically , loss of appetite since 10 days . Bilateral pedal oedema is present , facial puffiness is present
Past history
patient was diagnosed previously by right lobe aspergilloma on Tab itraconazole 200mg BD
No history of hypertension
No history of coronary artery disease
No history of Diabetes
No history of tuberculosis
No history of epilepsy
No history of asthma
No history of previous surgeries
Personal history
Diet - mixed
Appetite is normal
Bowel and bladder - normal and regular
No Known allergies
Addictions - occasional alcohol 2 pegs once monthly
Family history
His family members are not having any relevant issues
General examination
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Icterus is absent
Pedal edema - present (pitting type)
Pallor (mild) is present
No cyanosis, clubbing , lymphadenopathy
Vitals :
Temperature- febrile
Respiratory rate - 28 cpm
Pulse rate - 62 bpm
BP - 120/80 mm Hg.
Spo2 at room air is 96%
GRBS - 102 mg/dl
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard(vesicular)
Abdominal examination:
INSPECTION :
Shape of abdomen- scaphoid
-No tenderness of abdomen
- Umblicus - normal
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny
PALPATION :
No Local rise of temperature
Tenderness absent
Guarding present
Rigidity absent
hernial orifices normal
Fluid thrill absent
Liver not palpable .
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
RESPIRATORY EXAMINATION
Dyspnoea is present
wheeze is absent
position of trachea is central
normal vesicular breath sounds are heard
no adventitious sounds heard
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
Provisional diagnosis
Aspergilloma of right lung
Investigations
Right lower lobe aspergilloma of lung
(Chronic pulmonary aspergillosis)
Treatment
Tab DOLO 650 mg po/ TD
tab itraconazole 200mg po/BD
Tab hifenac BD
Tab Zofer
Comments
Post a Comment