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

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

27th February 2023 

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

Dr. K.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:  

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%  

Grbs : 27/2/23

8am-144

2pm-100

4pm-152

Grbs - 28/2/23

8am - 140mg/dl

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.

Palpation :

Soft, Non tender

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.

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.

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:

25/2/23

CBP:

Hb - 6.5 gm/dl

TLC - 22000 cells/ cumm

RBC - 2.91 million

PLT - 5.1 lakh

BGT - B positive

Hba1c - 6.4%

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 

USG ABDOMEN : 

Grade -I fatty liver

Hepatomegaly

 B/L raised Echogeneity of Kidneys

mild splenomegaly

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.