21 yr old female with fever,and burning micturition since 1 week

 21 year old female patient with fever , burning micturition since 1 week 

9th March 2023 

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21 year old female patient with Fever, burning micturition,pain and stiffness of both lower limbs.

Dr. M. Prathyusha ( Intern )

Roll no : 96

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 :  

21  year old female patient btech student came to opd with complaints of 

1. Fever since 1 week

2.pain and stiffness of both lower limbs since 10 days

3. Burning micturition since 1 week

4.cough since 3 days

HOPI : 

Patient was apparently asymptomatic 10 days  ago, then she developed pain and stiffness,cramps of both lower limbs,which relieved on taking rest and aggravated on walking.

H/o  fever which was high grade , associated with chills and rigors ,more during night time.

Fever associated with vomitings ,2 episodes since yesterday,contain food particles,non foul smelling

C/o cough since 2 days which is productive,whitish mucoid sputum,not blood tinged ,non foul smelling.

H/o generalised weakness.

H/o loss of appetite present since 1  week.

No H/o  pain abdomen , palpitations , vomitings , loose stools,sob,chest pain.

PAST HISTORY :

Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD, thyroid disorders.

PERSONAL HISTORY:

Appetite- lost

Diet - mixed 

Bowel - regular 

Bladder - burning micturition 

Addictions - No

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:-

Pt is C,C,C 

No icterus , cyanosis, clubbing, lymphadenopathy , pedal edema 

Vitals - 

Temp -98.9F

PR - 85bpm

BP - 110/70mmhg

RR - 17cpm

SpO2 - 99% at Room air 

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 :

Abdomen is soft in consistency.

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- Right upper limb 4/5

              Left upper limb 4/5

Right and left lower limb -3/5

Reflexes - Right.       Left

Biceps.        -               -

Triceps.      -                -

Supinator  -                 -

Knee.           -                 -

Ankle          -                  -

INVESTIGATIONS:

CBP:

Hb - 7.3 gm/dl

TLC - 6100cells/ cumm

RBC -  3.90 million

PLT - 4.4 lakh

CUE :

Albumin- nil

Sugars - nil

RFT: 

urea - 30mg/dl

Creatinine - 0.9mg/dl

Na - 136 mEq/L

K - 4.5 mEqL

Cl - 102mEq/L

Chest xray :

ECG:-

PROVISIONAL DIAGNOSIS : 

Pyrexia under evaluation

TREATMENT :  

1.IVF NS @75 ML/HR

2. INJ. OPTINEURON 1amp in 100 ml NS IV/OD

3. INJ.NEOMOL 1GM IV /TID

4. INJ.PAN 40 MG IV/OD

5. INJ.ZOFER 4MG IV/SOS

6. INJ. TRAMADOL 1amp in 100 ml NS IV/SOS

7.TAB.DOLO 650 mg po SOS