19 year old male with fever and lower back pain

19 Year old male with fever and lower backache

December 01,2022

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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

This is a case of 19 year old male from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of :

Fever since 4 days

Lower back ache since 4 days

Generalized weakness since 4 days

Abdominal pain since 4 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 10 days back then he developed high grade fever which was insidious in onset gradually progressive ,no diurnal variation which got relieved on medication given by local RMP [some IV medication was given for 1 day and oral medication is given].

Since 4 days he had high grade fever which was insidious in onset ,progressive and it is continuous not associated with chills and rigor ,no diurnal variation.

He had two episodes of vomiting 2 days ago which was non projectile contained food particles

He also complained of low back ache since 4 days which is insidious in onset ,gradually progressive, and is persistent and pain increased during inspiration and no relieving factors.[he was unable to describe the character of pain]

He also complained of abdominal pain which is insidious in onset persistent not associated with nausea and vomiting

He also complained of generalized weakness since 4 days

No history of burning micturition, increased frequency of urine ,difficulty to pass urine ,nocturnal eneursis

No history of loose stools

DAILY ROUTINE

He wakes up at 8 AM and does his morning routine , eats breakfast at 9 AM usually eats 4 idlies or 1 dosa or 4 bondas and goes to college at 9 AM by bus as his college is 10-25 km far from his home ,He is a CEC student attends all his classes and eat lunch at 2PM usually he eats junk foods [fried rice ,noodles,road side foods] almost daily as he feels embarrassed taking lunch box along with him , college ends at 4 PM ,comes back to home by 5 PM and eat dinner at 6 PM ,he usually prefers to eat rice in dinner. After having dinner he watches movies till 12 AM or go out with friends

His parents are agricultural labourer so sometimes he goes along with them Or sometimes he skips college and goes to work along with his cousin brother as part of recreation [ his cousin brother has plastic and iron shop where they store all the plastic and iron which they collected and sell them to others for reuse]

PAST HISTORY :

History of fever 10 days back which was diagnosed as typhoid and was given oral medication for 3 days and iv medication for 1 day

No history of Hypertension, diabetes, asthma, epilepsy,TB

No history of prolonged hospital stay

No history of previous surgeries

FAMILY HISTORY

No significant family history

PERSONAL HISTORY

Diet : mixed

Appetite: decreased since 4 days

Bowel and bladder:regular

Sleep:adequate

History of toddy and beer consumption occasionally

GENERAL EXAMINATION

Patient was conscious,coherent cooperative

Moderately build and moderately nourished

well oriented to time ,place and person

Pallor : no pallor,Lower palpebral congestion is seen

Icterus: absent

clubbing: absent

cyanosis: absent

Lymphadenopathy: absent

Edema : absent

VITALS:

Temp: febrile

BP: 110/80 mmHg supine position

PR- 90 bpm

RR- 16cpm

SYSTEM EXAMINATION:

Abdominal examination-

INSPECTION

On Inspection Abdomen is flat, no abdominal distension, umbilicus is central and inverted ,no engorged veins,no scars,sinuses,hernial ornifices are clear

PALPATION

All inspectory findings are confirmed

Tenderness present in epigastric region and right hypochondrium region

Tenderness present in right renal angle

Blanching present on Abdomen and back

liver dullness in 5th intercoastal space,