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35 year old female with fever and cough
This is is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
Patient came with complaints of fever since 2 months , cough since 20 days
HOPI -
Patient was apparently asymptomatic 2 months back then she had fever which is high grade , intermittent , associated with chills and rigor , relieved on taking medication
H/O cough since 20 days which is productive , greenish on color , non blood tinged
H/O loss of appetite present
H/O weight loss 15kgs in last 4 months
H/O SOB , grade II NYHA
No orthopnea , PND , chest pain , palpitations
No vomitings , loose stools
Past history :
N/k/c/o DM, HTN , TB, epilepsy , CVA , CAD , asthma
Treatment history:
Hysterectomy done 15 years back
Personal history :
Mixed diet
Appetite is decreased
Bowel and bladder movements - regular
Addictions - takes alcohol occasionally
General examination:
Patient is conscious, coherent , cooperative
Pallor present
No signs of icterus , clubbing, cyanosis , lymphadenopathy , edema
Vitals:
Temp - 102 F
PR -72 bpm
BP - 100/70 mmhg
Rr - 22cpm
Spo2 - 98% at RA
CVS -
S1, S2 present , no murmers
RS- BLAE + , NVBS heard
P/A - soft , non tender , no organomegaly
CNS - no FND
INVESTIGATIONS -
CUE -
colour - pale yellow
Appearance - clear
Albumin - nil
Sugar - nil
Bile salts - nil
Bile pigments - nil
Pus cells - 2 to 3
Epithelial cells - 2to 3
Rbc - nil
Casts - nil
Blood urea - 20mg/dl
Se .creatinine - 0.9 mg/dl
Sodium- 138meq/L
Potassium - 3.9 meq /L
Chloride - 101 meq/L
Calcium ionized- 1.04mmol/L
HbsAg - negative
Anti HCV - non reactive
Hiv - positive
LFT -
TB - 0.56 mg/dl
DB- 0.14 mg/dl
AST- 15 IU/L
ALT - 11 IU /L
TP - 6.4 gm/dl
ALP - 129 IU/L
Albumin - 2.99 gm/dl
A/G : 0.88
Widal test - negative
Culture and sensitivity-
Gram stain- 10-15 epithelial cells , 4-5 pus cells seen , moderate gram positive cocci , few gram negative bacteria
ZN stain- no acid fast bacilli seen
Sputum for CBNAAT - positive
DIAGNOSIS :
VIRAL PYREXIA
DENOVO RETRO VIRAL DISEASE
PULMONARY TUBERCULOSIS
Treatment -
1. IVF NS, RL @75ml/hr with 1 Amp OPTINEURON
2.INJ.NEOMOL 1gm IV/SOS IF TEMP > 101F
3. Tab.PCM 650mg PO/QID
4. tab. AUGMENTIN 625mg PO/BD
5. Tab.MONTEC IC PO/HS
6.Tab. PAN 40mg PO/OD
7. syp.GRILINCTUS 10ml PO/TID
8. Syp.ARYSTOZYME 10ml PO/BD
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