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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.






This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



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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