28year old male patient with fever, cold and cough

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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 the case of a 28 year old male, resident of Lingotam farmer by occupation who came to OPD with Chief Complaints of

Fever since 6 days 

Cold and Cough since 5 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6days ago, then he developed developed fever which is sudden is sudden in onset and is intermittent which is aggravated during nights and is relieved in the morning. Fever is associated with chills.

Then 5 days ago he developed cough which was sudden in onset and productive. 

Sputum was yellow in colour without blood.

On the same day he developed cold which was associated with noseblock.He was then admitted in our hospital 3 days ago.

PAST HISTORY:

The patient had an accident 10 years ago after which he underwent a liver surgery for it.

Then 5years ago he was diagnosed with Acute Appendicitis when he complained of severe stomach pain over right abdominal area. He underwent Appendectomy for it.

Patient is not a known case of Diabetes mellitus, Hypertension, TB, epilepsy.

SURGICAL HISTORY:

Patient had a history of liver surgery 10 years back and history of Appendectomy 5years ago.

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Bowel and bladder movements: Regular

Sleep: Normal

No addictions

FAMILY HISTORY:

No relevant family history

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative, he is well oriented to time, place and person.

He is moderately built and nourished.

No Pallor, Icterus, Clubbing, Cyanosis, Lymphadenopathy and Edema

Vitals:

Temperature: Afebrile

Blood Pressure: 120/70mmHg

Pulse rate: 73 bpm

Respiratory rate: 15cpm

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection : 

On inspection shape of chest is normal. It is bilaterally symmetrical. There are no scars and trachea is centrally placed.

Respiratory movements are symmetrical on both sides.

Palpation:

All inspectory findings are confirmed.

All quadrants move equally with respiration.

Vocal fremitus:

Supraclavicular same on both sides

Infraclavicular same on both sides

Supramammary same on both sides 

Inframammary same on both sides

Suprascapular same on both sides

Infrascapular same on both sides

Interscapular same on both sides

Percussion:

Resonant note is felt on both the sides

Auscultation:

Other than the normal breath sounds no other breath sounds are found.

CVS :

S1 and S2 are heard

No murmurs

 

CNS:

No focal neurological deficits

Per Abdomen:

Normal, soft and non- tender

INVESTIGATIONS:

Hemogram

Serum electrolytes:

Serum creatinine:

Liver Function tests:

ECG:

PROVISIONAL DIAGNOSIS:

Upper Respiratory tract Infection?