71 year old female patient with complaints of fever, cough and cold

71 year old female patient with complaints of fever, cough and cold


26th February 2023 


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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


26 year old female patient with complaints of fever , cough and cold.


Dr. M. Anurag ( Intern )

Roll no : 84


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.


CASE:  

71 year old female patient came to the Casuality with complaints of 

1. Fever since 15 days 

2. Cough since 3 days 

3. Cold since 4 days  


Patient was apparently asymptomatic 15 days back then she developed fever which is high grade , intermittent , releived on medication . Not associated with chills and rigors. 

No C/o vomiting, loose stools , pain abdomen 

Complaints of cough since 3 days which is non productive, sporadic. Not associated with seasonal/diurnal variation . 


PAST HISTORY :  

K/C/O DM - 2 since 6yrs ( on regular medication of glimiperide 2mg + Voglibose 0.2mg + Metformin 500 mg PO/BD) 

K/C/O Hypertension since 20 years ( On regular medication of Telmisartan 40mg  + Hydrochlorothiazide 12.5 mg )

Not a k/c/o TB ,epilepsy, asthma,CAD,CVD, Thyroid disorders. 

Patient has a surgical history of Hysterectomy done 30 years ago and Hernial Surgery done 10 years ago. 


PERSONAL HISTORY:

Appetite- Decreased since 15days

Diet - Vegetarian

Bowel - regular 

Bladder - Burning micturition since 3 days, Nocturia

Addictions - None 


FAMILY HISTORY:

No significant family history 


GENERAL EXAMINATION:

Pt is C,C,C 

No pallor, icterus , cyanosis, clubbing, lymphadenopathy , pedal edema 






 


Vitals - 

Temp -98.6F

PR - 106bpm

BP - 120/80 mmhg

RR - 18cpm

SpO2 - 98% at Room air 

Grbs - 122mg%  

  


SYSTEMIC EXAMINATION :


PER ABDOMEN :

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No sinuses , engorged veins, visible pulsations .

Hernial orifices are free.


Palpitation :

Soft, Non tendee

No organomegaly.

Liver and Spleen - Not palpable 

Percussion : Tympanic note heard over the abdomen.


ToAuscultationon:

Bowel sounds are heard.


CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves

Auscultation :

S1 and S2 heard.


RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.


CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right  Left

Biceps      ++        ++

Triceps.   ++.        ++

Supinator ++       ++

Knee.         ++.      ++

Ankle        ++.       ++




INVESTIGATIONS:

CBP:

Hb - 6.5 gm/dl

TLC - 22000 cells/ cumm

RBC - 2.91 million

PLT - 5.1 lakh


RFT: 

urea - 49 mg/dl

Creatinine - 1.8 mg/dl

Na - 134 mEq/L

K - 4.5 mEq/L

Cl - 104 mEq/L


LFT :

TB- 0.65 mg/dl

DB- 0.20mg/dl

SGPT - 18 IU/L

SGOT - 20 IU/L

ALP - 328 IU/L

TP - 5.8

Albumin - 2.7gm/dl 

A/G ratio : 0.85 


CHEST XRAY :




27/02/23 :

Dengue NS 1 antigen , IgG , IgM - Negative

Blood for MP Strip test - Negative

Serum Iron - 69.5ug/dl


CBP: 27/2/23

Hb - 6.1 gm/dl

TLC - 17840 cells/ cumm

RBC - 2.83 million

PLT - 4.77 lakh


Usg Chest : 

Elo moderate free fluid noted in the left pleural spaces

E/O mild consolidatory changes noted in B/L Lower lung fields.

Impression : 

Left moderate pleural effusion

B/L Consolidatory changes 


28/2/23 :

CBP :

Hb - 6 gm/dl

TLC - 12700 cells/ cumm

RBC - 2.74 million

PLT - 4.60 lakh


Serum ferritin - 38.5ng/ml


PROVISIONAL DIAGNOSIS: 

Pyrexia under evaluation with uncontrolled diabetes mellitus, with anemia under evaluation


TREATMENT

1. Inj. Monocef 1gm IV BD 

2. Inj. Neomol 1gm IV SOS 

3. Tab. PCM 650mg PO TID 

4. Tab. Levocetrizine 5mg PO OD 

5. Syr. Ascoryl D 15ml PO OD 

6. Tab. Amlodipine 5mg PO OD 

7. Inj. HAI s/c acc. to sliding scale. 

8. Strict grbs 7 unit profile 

9. Monitor vitals 4rth hourly.


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