case 5
Sravani pylla
12/09/23 - 60F with headache since 1 month and fever with productive cough since 10 days
on September 11, 2023
Hi, I amsravani Pylla, 5th sem medical student. This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint:
60 Year old female, resident of Suryapet, daily wage laborer by occupation came to OPD with chief complaints of
- headache since 1 month
- fever since 10 days
- cough since 10 days.
History of Present Illness:
Patient was apparently asymptomatic 1 year ago when she developed shortness of breath of grade 1, no orthopnea, no PND, no chest pain.
She had headache since 1 month, of diffuse type in the parietal region which radiates to neck and lower back.
It was associated with productive cough since 10 days, aggravated by exposure to cold weather, not relieved by medication, no diurnal variation, and the sputum is white in colour and mucoid in nature.
She also has fever since 10 days of high grade, associated with chills and rigor, no sweating, intermittent, no diurnal variations.
No h/o chest pain, sweating, palpitations, loose stools, nausea, vomiting, burning micturition, decreased urine output and weight loss.
Daily Routine:
Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.
After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past History:
similar complaints 2 months ago of fever, headache and body pain which was relieved on medication (antibiotics and painkillers)
Not a k/c/o DM, HTN, CAD, TB, epilepsy.
Surgical history: she had a tubectomy done 20 years ago following which she had dysmenorrhea which was managed by a hysterectomy.
Personal History:
- married
- decreased appetite
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- addictions: toddy drinker but ceased 20 years ago.
Family History: not significant
Drug History
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- pallor present
- no icterus
- no cyanosis
- clubbing of fingers present
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- Temperature: 95°F
- Pulse: 88/min
- RR: 20 cycles/min
- BP: 130/70 mm Hg
Fluid Intake and Urine Output
Total Input: ml
Total Output: ml
Fever chart :
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- wheeze present in bilateral suprascapular, infrascapular and mammary areas
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals:
- speculum examination :
- P/R examination :
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordinatioInvestigations:
X Ray -
ECG -
Hemogram on 11/09/
23 -
Hemogram on 12/09/23 -
Malaria Parasite testing (negative) -
Provisional Diagnosis:
Pyrexia secondary to lower respiratory tract infection with h/o bronchial asthma (exacerbation)
Treatment:
INJ. Neomal 1gm iv
TAB. Paracetamol 650mg
TAB. Levocetrizine
SYRUP. Ascoril- LS
TAB. Azithromycin
TAB. Amoxicillin n: not seen
- gait: normal
