38yr old female with complaints of fever,cold,cough,burning micturition

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38 year old female patient with complaints of fever, cold, cough, burning micturition 

Dr.Ankitha (Intern)

Roll no : 78

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:  

38 year old female patient came with complaints of 

1. Fever since 6 days 

2. Cough since 6 days 

3. Cold since 6 days

4. Burning micturition since 6 days  

Patient was apparently asymptomatic 6 days back then she developed fever which is high grade , intermittent , relieved on medication . Not associated with chills and rigors. 

No C/o vomiting, loose stools , pain abdomen 

Patient also has complaints of cold and cough which is non productive, sporadic. Not associated with seasonal/diurnal variation . Associated with body pains , sore throat

Complaints of burning micturition since 6 days

No H/O urgency, hesitancy , incontinence , poor stream.

H/O tingling sensation in right lower limb with no complaints of paresthesia , numbness

Complaints of polydypsia but no complaints of polyphagia , polyuria 

PAST HISTORY : 

K/c/o DM since 12years ( on regular medication of Inj. HAI - 24U——X——25U

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

PERSONAL HISTORY:

Appetite- Normal

Diet - Non Vegetarian

Bowel - regular 

Bladder - Burning micturition since 6 days

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 - 76bpm

BP - 120/70 mmhg

RR - 16cpm

SpO2 - 98% at Room air 

Grbs - 201mg%  

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpation :

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.

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.

Palpation :

Soft, Non tender

No organomegaly.

Liver and Spleen - Not palpable 

Percussion : Tympanic note heard over the abdomen.

Auscultation :

Bowel sounds are 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        ++.       ++

REFERRAL :

OPHTHALMOLOGY REFERRAL : 28/02/23

Impression :

Anterior segment and fundus are within normal range and diabetic retinopathy changes are not noted.

INVESTIGATIONS:

Chest Xray :

ECG : 

25/2/23 :

RFT : 

Blood Urea - 34mg/dl

Creatinine - 1.2 mg/dl

Na - 136 mEq/L

K - 3.8 mEq/L

Cl - 100 mEq/L 

LFT :

TB- 0.98 mg/dl

DB- 0.20 mg/dl

SGPT - 10 IU/L

SGOT - 11 IU/L

ALP - 144 IU/L

TP - 6.5

albumin - 3.5 gm/dl

Blood for M.P Strip test - Negative

CBP:

Hb - 11 gm/dl

TLC - 7900 cells/ cumm

RBC - 4.44 million

PLT - 2.14 lakh

FBS - 

Usg Abdomen :

Impression - Grade II fatty liver

26/2/23 :

FBS - 280mg/dl

27/2/23

Urine for ketone bodies - Negative

28/2/23

CBP :

Hb - 11.7 gm/dl

TLC - 6700 cells/ cumm

RBC - 4.73 million

PLT - 2.10lakh

PROVISIONAL DIAGNOSIS: 

PYREXIA Under EVALUATION (?VIRAL) (resolving) with Uncontrolled Type II DM

TREATMENT: 

1. Inj.HAI s/c acc to grbs premeal/TID
2. Inj.NPH s/c acc to grbs premeal/BD
3. Tab.PCM 650mg Po/SOS
4. TAB. AZITHROMYCIN 500mg po/OD
5. TAB. LEVOCETRIZINE 5mg PO/OD/HS
6. SYP. ASCORYL-D 10ml plPo/TID
7. Grbs 7hr profile monitoring