13 year old female patient with complaints of fever since 5 days , cough since 4 days and cold since 4 days
01 April 2023
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13 year old female patient with complaints of fever since 5 days , cough since 4 days and cold since 4 days
70 year old female patient with Shortness of Breath
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:
13 year old female patient with complaints of fever since 5 days , cough since 4 days and cold since 4 days
HOPI:
Patient was apparently asymptomatic 5bdays back then she developed fever since 5 days, sudden in onset , high grade , associated with chills and rigors, releived on medication. Cough since 4 days - productive , white in colour , no blood tinges , non foul smelling , no diurnal variation , cold since 4 days.
No H/O burning micturition, shortness of breath, vomitings , loose motions.
PAST HISTORY :
Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD.
PERSONAL HISTORY:
Appetite- Normal
Diet - mixed
Bowel - regular
Bladder - Normal
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 -98.8F
PR - 104bpm
BP - 100/70 mmhg
RR - 20cpm
SpO2 - 98% at Room air
Grbs - 121 mg%
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 :
Abdomen is soft in consistency.
No organomegaly.
Liver and Spleen - Not palpable
Percussion : Tympanic note heard over the abdomen.
Auscultation:
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 ++ ++
CHEST XRAY:
INVESTIGATIONS:
CBP:
Hb - 10.5 gm/dl
TLC - 1800 cells/ cumm
RBC - 3.78 million
PLT - 1.23 lakh
CUE:
Albumin : ++++
Sp. Gravity : 1.010
Sugars : nil
Bile salts : nil
Bile pigments : nil
Pus cells : 1- 2
CRP : Negative
Spot urine protein creatinine ratio : 0.39
Dengue NS1 antigen , IgM , IgG : Negative.
PROVISIONAL DIAGNOSIS :
Pyrexia under evaluation with Neutropenia
TREATMENT :
1. Tab. PCM 500mg PO/TID
2. Syr. Ascoryl 10ml PO/TID
3. Inj. Neomol 1gm IV/SOS
4. Temperature monitoring 4rth hourly
5. Vitals monitoring.
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