32 yr old male with pain abdomen

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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 come up with diagnosis and treatment plan.

 Cheif complaints:

Pain abdomen since 7 days 

Fever since 7 days 

HOPI : Patient was apparently asymptomatic 7 days back then he developed fever which is sudden in onset Gradually progressive high grade increased during night times associated with chills and rigor no aggravating factors temporarily releived on medication. 

He also had pain abdomen since 1 week which was insidious in onset ,gradually progressive,in right hypochondrium right lumbar and umbilical region which was pricking type non radiating aggravated on inspiration ,no relieving factors.

History of cough since 3 days insidious in onset dry cough relieved on taking cough syrup. 

H/o night sweats,weight loss seen

No H/o sore throat,runny nose,sneeze, nasal congestion,headche

No h/o nausea,vomiting,loose stools,constipation,abdominal distension

No h/o dyspnea,wheeze

No h/o chest pain,palpitations,orthopnea,pnd 

No h/o hoarseness of voice,hemoptysis,burning micturition,decrease urination 

Past history:

N/k/c/o Dm,Tb,asthma,epilepsy,cad,thyroid disorders

Personal history:

Diet mixed

Appetite normal

Sleep disturbed

Boweland bladder regular 

Addictions- Has a habit of drinking alcohol occasionally 

Family history: No relevant family history 

Treatment history: Pleural tap done on 14.04.23(20ml) and on 15.04.23(30ml) 

 General examination:

Patient was conscious coherent cooperative moderately built and moderately nourished 

Has no signs of 

Pallor-Absent

Icterus-absent

Cyanosis-absent 

Clubbing-absent 

Koilonchyia-absent

Lymphadenopathy-absent 

Edema- absent 

 Vitals: 

Pulse:86

Bp:120/80mmhg

Temp: Afebrile 

RR: 16cpm

Systemic examination: 

Respiratory:

Inspection: 

Shape of chest elliptical

Chest movements appears to be normal 

Trachea appears to be central 

No scars sinuses engorged veins 

No hallowing 

No  drooping of shoulders 

Palpation: 

All inspectory findings confirmed

Rise of temp was seen 

No tenderness 

Trachea central 

No swellings and palpable masses 

No crepitus or wheezes heard 

Abdomen:

Inspection:

Shape of abdomen scaphoid 

Umbilicus inverted 

No scars sinuses engorged veins 

No visible peristatlsis 

No visible pulsations 

Palpation: 

Rise of temperature seen 

Tenderness in right hypochondrium ,right lumbar,umbilical region 

Percusioon: 

No shifting dullness 

No fluid thrill 

Auscultation: bowels sounds (8/min) were heard 

CVS :

Inspection: 

No chest wall abnormalities 

No scars sinuses sinuses engorged veins 

Trachea appears to be central 

Apical impulse not visible 

Palpation: 

Apical impulse felt at 5th ics 1cm medial to midclavicular line 

No parasternal heaves 

No thrills 

Auscultation:

S1 s2 heard no murmurs 

Cns:

Higher mental functions :intact ,normal 

Cranial nerves :normal 

Sensory examination: Normal sensations felt in all dermatomes 

Motor examination: normal tone,power in upper and lower limbs, normal gait 

Reflexes: B/l elicited 

Cerebella’s function: normal 

No meningeal signs were elicited 

Diagnosis:

Right sided pleural effusion sec to Tb 

Mild hepatosplenomegally 

Investigations:

Ada -Pleural fluid 

Pleural fluid 

X ray 

Usg:

Ecg: 

Treatment:

Iv fluids NS 

Inj neomol 1gm iv 

Inj tramadol 1amp in 100 ml of NS

Inj pan 40mg 

T.azithromycin  500mg 

Tab ATT 

4 tabs H 340mg,R 680mg,Z 1700mg,E 1020mg 

Tab PCM 650mg 

Syrup grilintus 15ml 

Tab pyridoxine 25mg 

Inj diclofenac I.m