32 year male c/c fever stomach pain

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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.

32 year old male farmer by occupation resident of suryapet came to opd with 

Chief complaints : 

Fever since 1 week 

Stomach pain at right side since 1 week

HOPI

Patient was apparently asymptomatic 1 week back then he developed fever which is sudden in onset ,continous,gradually progressive associated with chills and rigors,evening rise of temperature was present with night sweats.no aggregating factors ,temporarily relieved by medication 

Patient also complained of abdpmen pain since 1 week in right hypochondriac,rt.lumbar,umbilicus region aggrevated on inspiration and relieved by rest

H/O cough since 3 days ,insidious in onset,non productive type,non blood stained,non foul smelling

No h/o post nasal drip,cold,hoarseness of voice,noseblock

No h/o dyspnea,chestpain,palpitations

No h/0 PND,orthopnoea

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

Past history 

H/o admission in hospital due to same complaints 

Not a K/C/O DM,HTN,TB,asthma,CAD,thyroid disorder 

PERSONAL HISTORY:

Mixed diet

Adequate sleep

Regular bowel and bladder movements

No smoking and no allergies

Ocassional alcohol consumer

FAMILY HISTORY:

not significant

GENERAL EXAMINATION:

Patient is c/c/c

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.

Temp-Afebrile 

BP- 

PR - 

RR - 

R/S - inspection:

Trachea appears to be normal - Central 

shape of chest - elliptical 

Movements of chest appear to be bilaterally equal

No scars , sinuses present.

No drooping of shoulder

No engorged veins , swellings seen

No hallowing seen

No crowding of ribs

Palpation:

All inspectory findings are confirmed

 rise of temperature present

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt

vocal fremitus 

                                            RT.            LT

SUPRA CLAVICULAR       Normal.      Normal

INFRA CLAVICULAR.       Normal.       Normal

MAMMARY.                       Decreased.  Decreased 

INFRA MAMMARY.           Decreased.  Decreased 

AXILLARY.                         Decreased.   Decreased 

INFRA AXILLARY.             Decreased.  Decreased 

SUPRA SCAPULAR.         Normal.     Normal

INFRA SCAPULAR.         Normal.      Normal

INTER SCAPULAR.          Normal.    Normal

PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       Dull.          resonant

INFRA MAMMARY.           Dull.        .  resonant

AXILLARY.                         Dull.          resonant

INFRA AXILLARY.             Dull.           resonant

SUPRA SCAPULAR.       Resonant  resonant

INFRA SCAPULAR.         resonant   resonant

INTER SCAPULAR.          resonant   resonant

Auscultation 

Bilateral airway entry present

Normal breath sounds heard

PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       NVBS.        NVBS

INFRA CLAVICULAR.       NVBS.         NVBS

MAMMARY.                       decreased    NVBS

INFRA MAMMARY.           Decreased    NVBS

AXILLARY.                         Decreased    NVBS

INFRA AXILLARY.             Decreased    NVBS

SUPRA SCAPULAR.       NVBS.             NVBS

INFRA SCAPULAR.         NVBS.             NVBS

INTER SCAPULAR.          NVBS.            NVBS

Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard

Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

Central nervous system:

Conscious

Normal speech.

No neurological deficit found.

Provisional diagnosis 

Pleural effusion right side 

Secondary to tuberculosis