80 year old female presented with the complains of fever since 3 months,burning micturition since 3 months,difficulty in swallowing since 1 month

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 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 , she was also suspected to have TB and treated with anti-tubercular therapy

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 

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

Menopause attained 30 years back



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 

 Vitals

Bp:150/90mmhg

RR-20cpm

PR-98bpm



SYSTEMIC EXAMINATION :

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, TENDER

PROVISIONAL DIAGNOSIS:  

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS



INVESTIGATIONS:

REPORTS-

Fever chart-


2D ECHO -

Bacterial culture and sensitivity 
USG


Neck USG

X-RAY


HRCT CHEST

DX:80F WITH PYREXIA OF UNKNOWN ORIGIN ASSOCIATED WITH SCM TENDINITIS AND CHOLELITHIASIS , ANEMIA OF CHRONIC INFLAMMATION WITH HYPERTENSION & DIABETES.

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