32 yr old female with Fever and Neck pain

MEDICINE CASE DISCUSSION : 

 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 individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable comments on comment box is welcome. 

K. Ankitha reddy, 9th semester
Rollno : 67

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. 


CASE

32 year old female , Farmer by occupation, resident of kattangur came with
Chief Complaints of
 1. Neck pain since 5days.

2. Fever with chills since 3 days (admitted on 20.10.2021) 

3. Body pains since 3 days 

4. Nausea and Vomitings since 2 days

5. Giddiness since 2 days 

7. Palpitations since 1 day 


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back then she developed neck pain which is insidious in onset and gradually progessive dragging type of pain. No aggrevating and relieving factors. 

Then she developed fever 3 days back which is of high grade, continuous type of fever and  associated with chills and rigours. Relieved on medication. 

Patient had history of one episode of vomiting for which she came to hospital on 19/10/21, took medication and left.
It is non bilious and non projectile.

Patient has history of body pains since 3 days

There is history of headache which is of diffuse type associated with nausea.

No history of cold, cough. 

She also has palpitations since 2 days , more during morning time. 

One day after admission she is experiencing throat pain and difficulty in swallowing. 


# She also has a history of hair loss since 3 years

Weight loss since 3 years 

History of excessive sweating. 

No history of Bowel irregularities. 

MENSTRUAL HISTORY :

Age of Menarche 14 yrs 
Marital life : 17 years
Cycles : Irregular menstrual cycles since 2 yrs
* 6/20 ; 4 pads/ day
Clots present
Bleeding increased since 2 yrs

PAST HISTORY:

Episode of  fever 14 days back after taking COVID vaccine, after which she had vomitings for 4 days  4-5 episodes/day ,visited rmp took medications and was fine
5 months back she c/o giddiness and she visited RMP  where she was diagnosed of low BP

There is no history of Diabetes, hypertension,asthma , tuberculosis.

PERSONAL HISTORY:

 Diet - mixed

Appetite - decreased since 5 days. 

Sleep - adequate

Bowel and bladder- regular

Addictions - no addictions

Allergies - None 

FAMILY HISTORY:

There is no significant family history


GENERAL EXAMINATION:

Pateint  is conscious , coherent , cooperative. 

Moderately built and moderately nourished.

#Pallor - present

No Icterus 

No cyanosis

No clubbing

#Cervical lymphadenopathy present

No bilateral pedal edema


VITALS


Temperature - febrile

Pulse rate -82 BPM

Blood pressure -90/60 mm of Hg

Respiratory rate - 16 cpm


EXAMINATION OF NECK  

On Inspection : A diffuse swelling is noticed on the anterior neck region which is moving on swallowing.
On Palpation, Diffuse swelling is present which is firm in consistency
Lower margin is palpable.

On palpation of lymph nodes , multiple cervical lymph node enlargement is seen  bilaterally at level of posterior triangle. 

Swelling is tender, smooth ,mobile, firm in consistency.


SYSTEMIC EXAMINATION:

CVS - S1 , S2 heart sounds heard
no murmurs

RESPIRATORY SYSTEM -bilateral air entry present
Normal vesicular breath sounds heard

ABDOMEN - soft and non tender

                       Bowel sounds are heard

                     No organomegaly

CNS- intact 

        No signs of meningeal irritation 





INVESTIGATIONS : 

20/10/21 :

HAEMOGRAM : 

#Hb : 7.2gm/dl


PACKED CELL VOLUME



COMPLETE URINE EXAMINATION



LIVER FUNCTION TESTS



RANDOM BLOOD SUGAR


SERUM ELECTROLYTES


T3,T4 ,TSH

#TSH : 5.94


SERUM FERRITIN 




ULTRASONOGRAPHY :

Impression : 1. Diffuse thyroid disease most likely thyroiditis. 
2. Cervical lymphadenopathy




PROVISIONAL DIAGNOSIS :

Cervical lymphadenopathy with thyroiditis

TREATMENT:

On 21.10.2021.

Tab .RENERVE-P  75 mg  2 times a day

Tab .DOlO 650 mg  3 times a day

Tab .ZOFER 4 mg PO/OD

Tab .ULTRACET 1/2 tab QID 

Plenty of oral fluids 

On 22.10.2021

Tab.PCM 500 mg /PO / TID 

IVF normal saline and ringers lactate -50 ml / hr.

Tab.OROFER/ PO/ BD 

Oral fluids 

Tab . ULTRACET  4 times a day for 3 days 

Inj .MONOCEF 1 gm /IV / BD






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