General Medicine
A 13 year old male with fever and bilateral lymphadenopathy.
25,August, 2022
E LOG GENERAL MEDICINE
Hi, I am pindi Gayatri , 3rd Sem Medical Student.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 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.
CHIEF COMPLAINTS
A l3 year old male came to the casuality with the chief complaints of neck pain since 2 days,difficulty in swallowing since 2 days,neck swellings and facial puffiness since 1 day on 25th, August.
HISTORY OF PRESENT ILLNESS
He came to the hospital with the complaints of neck pain and difficulty in swallowing since 2 days.Neack sweelings and swelling all over the facesince last night relieved on using medications.
Pain below the right ear since last night.
Patient was apparently normal till nov 2021,then he had high grade fever associated with chills,diagnosed with dengue fever.In march 2022 patient had similar episode of neck sweelings and difficulty in swallowing.
Treated conservatively on op basis.
Since 2 days patient initially had neck pains during swallowing associated with neck swellings and difficulty in swallowing,low grade fever and facial puffiness.
HISTORY OF PAST ILLNESS
Not a known case of hypertension, Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.
No history of joint pains,SOB ,palpitations,blurring of vision,burning micturition,nausea,vomitings,loose stools,skin infections.
TREATMENT/DRUG HISTORY
No Diabetes
No hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No Chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Single
Occupation-student
Diet-mixed
Appetite-normal
Bowels-regular
Micturition -normal
FAMILY HISTORY
No Diabetes, hypertension, heart disease, stroke,cancers,TB,Asthma.
Family History - recurrent sneezes,sinusitis(both mother,father).
Younger brother history of fever with cervical lymphadenopathy 2 years ago.
FNAC-reactive lymphadenitis with tonsillitis.
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers /toes
No oedema of feet
No malnutrition
No dehydration
VITALS
Temperature- 98°F
Pulse rate- 84 bpm
Respiratory rate- 14 cpm
Blood pressure-120/70 mmHg(left arm)
SpO2 at room air-98%/at RA litres of 02
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds heard
No dyspnea
No wheeze
ABDOMEN
Shape of the abdomen-scaphoid
No tenderness
No palpable masses
Normal hernial orifices
No free fluid
No bruits
Non palpable liver
Non Palpable spleen
No Bowel sounds
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Reflexes
Biceps triceps supinator knee ankle
Right + + + + +
Left + + + + +
Plantars-flexor
Cerebral Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
INVESTIGATIONS
Adviced for ENT-examination in view of tonsillopharyngitis.
RECORDINGS
