S vikas Varma roll no 1701006154

January 01, 2023

 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"

 55year 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) , not 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 (300mg) 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 300mg 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 

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 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


Investigations












Provisional diagnosis

Right lower lobe aspergilloma 

Treatment

Tab DOLO 650 mg po/ TD
tab itraconazole 200mg po/BD
Syp ascoril 2 tsp bd 1 week
Tab pan 40mg od 1 week
Tab mvt od 20 days

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