Patient History of Infective Endocadritis

8/19/2019 Patient History of Infective Endocadritis

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History

Personal Profile

1. Name Waqar Ali

2. Age 20 year

3. SexMale

4. Martial status Unmarried

5. Religion Muslim

. Address !tte"ad #olony

$. %ro&ession Ri'(s"a) dri*er

+. ,ate o& Admission Wednesday 30 A-ril 2014

. Mode o& Admission /mergen'y


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4/28

Presenting Complaint

Fever 2 month


5/28

History of Presenting Illness

M a!ien! i" n$*n I+ dru' abu"er %$r la"! , ear n$*re"en!ed *i!h c$mlian! $%

Fe-er

1. Sudden in onset A'ute

2. ig" grade

3. #"ills Rigors

4. Remittent

5. Relie*ed y Medi'ation

. Asso'iated )it" S67 )eig"t loss7 Nig"t s)eat 78oint -ain 7 mus'le -ain

&atigue and A--re"ension


6/28

Systemic History #9S

1.%al-itation

2. Mild #"est -ain

3. 6reat"lessness

4. /dema

Res-iratory

1. No 'oug" 7 s-utum 7 )"ee:ing and no lood in s-utum

;.!.<

1. Anorexia 7 nausea

2. No regurgitation7 "eart urn. ,iarr"ea 7 *omiting7 'onsti-ation7 llod


7/28

Urinary System

1. No -ain in &lan(7 dysuria7 lood in urine7 -olyuria7

Ner*ous system

1. ;enerali:e )ea(ness

2. eada'"e

3. No numness7 tingling7 &its7 di-lo-ia7 *isual loss

Mus'ulos(eletal

1. %ain and s)elling in 8oints

2. Restri'tion o& =oint Mo*ement

3. Mus'ular -ain


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Past History

Past Medical History

1. None

Past Surgical History

1. None


9/28

Drug History

,rug Allergy

1. e is not (no)n allergi' to any drug

,rug inta(e "istory

1. e is not ta(ing any drug regularly

,rug treatment istory

1. >or &e*er "e )as treated y ?o'al %"ysi'ians "e does not (no) t"e -res'ri-tion


10/28

Family History

No -ositi*e >amily "istory o&


11/28

%ersonal istory

!9 drug auser 2 year

Al'o"oli' 2 year

Smo(er 2 year

#o'aine and -ium 2 year


12/28

Socioeconomic

e elong to a lo) so'ioe'onomi' status


13/28

General Physical Eamination

My -atient )as lying su-ine on ed si'(@loo(ing7 mildly agitated )it" 'annula onle&t "and

9itals

1. 6.% 100+0 mmg

2.

3. Res-iratory Rate 22 6reat" min

4. %ulse 11 eatsmin

5. xygen saturation $C


14/28

Hand

1.


15/28

!rm and Forearm

./ Scar Mar"

,/ 0a!!$$in'

1/ I+ In2ec!i$n Mar"

3/ N$ e!echia4 r$5imal m$a!h4

lmh n$de enlar'emen!


16/28

Face

1. /x-ression less &a'e

2. #on8u'ti*al -eta'"iae

3. %oor ral ygiene

4. ral


17/28

$o%er $im&

./ 6lubbin' #re"en!

,/ 6an$"i" #re"en!

1/ Edema #re"en!

3/ &$il$nchia Ab"en!

7/ L$"" $% Hair Ab"en!

8/ #i'men!a!i$n Ab"en!

9/ #e!achiae Ab"en!

:/ ;r$in Lmh n$de N$ alable


18/28

Cardiovascular Eamination

Inspection

1. No s'ar mar( 7 6ulging o& -eri'ardium no '"est de&ormity and *isile -ulsatio

and -rominent *ein

.Sacral edema !&sent

.Pitting Pedal edema Present


19/28

Palpation

%ulse

1. Rate 11 -ulsesmin

2. R"yt"m Regular

3. 9olume ig" 9olume

4. #"ara'ter No S-e'i&i' #"ara'ter

A-ex eat 5t" !#S medial to Mid 'la*i'ular ?ine


20/28

!uscultation

./ Murmur S"!$lic


21/28

'ther Systemic Finding

(espiratory

>ine asal 're-itation on ot" sides

G)I)*

S-leenomegaly

C"S

All Re&lex inta't and no &o'al neurologi'al Sign

MusculoS#eleton

6ilateral Fnee =oint s)elling and restri'tion o& mo*ement


22/28

Differential Diagnosis

R"eumati' &e*er

Myo'arditis

R"eumatoid Art"ritis

%rimary eart neo-lasm

Anti@%"os-"oli-id syndrome ?yme disease

Rea'ti*e Art"ritis

S?/


23/28

Investigation

+aseline

1. #6#

10gdl

W.6.# 137200

/SR Raised

2. %eri-"eral Smear %oi(ilo'ytosis


24/28

Urine /xamination

#"est G ray

• 6ilateral mild 'onsolidation

e-atitis 6 and # serology

Anit#9 H*e

!9 Serology

!9 H*e

?>


25/28

Specific Investigation

ECG

?ong %R inter*al S< ,e-ression

ECH'C!(DI'G(!M


26/28

*yphidot "egative

MP smear "egative

,ltrasound !&domen

S-lenomegaly And Mild As'ites

Serological *est

ANA Ne'a!i-e

RA %ac!$r Ne'a!i-e

614 63 c$mlemen!" N$rmal

AS> 0i!!er .,?


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Diagnosis

I


28/28

Diagnosis

!n&e'ti*e /ndo'arditis

Documents

Patient History of Infective Endocadritis