32 yr old female with fever and neck pain
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M.Tharun kumar 9th semester
Rollno : 87
I've 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 a diagnosis and treatment plan.
CASE
32 year old female , Farmer by occupation, resident of kattangur came with
Chief Complaints of
1. Neck pain since 5days.
2. Fever with chills since 3 days (admitted on 20.10.2021)
3. Body pains since 3 days
4. Nausea and Vomitings since 2 days
5. Giddiness since 2 days
7. Palpitations since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 days back then she developed neck pain which is insidious in onset and gradually progessive dragging type of pain. No aggrevating and relieving factors.
Then she developed fever 3 days back which is of high grade, continuous type of fever and associated with chills and rigours. Relieved on medication.
Patient had history of one episode of vomiting for which she came to hospital on 19/10/21, took medication and left.
It is non bilious and non projectile.
Patient has history of body pains since 3 days
There is history of headache which is of diffuse type associated with nausea.
No history of cold, cough.
She also has palpitations since 2 days , more during morning time.
One day after admission she is experiencing throat pain and difficulty in swallowing.
# She also has a history of hair loss since 3 years
Weight loss since 3 years
History of excessive sweating.
No history of Bowel irregularities.
MENSTRUAL HISTORY :
Age of Menarche 14 yrs
Marital life : 17 years
Cycles : Irregular menstrual cycles since 2 yrs
* 6/20 ; 4 pads/ day
Clots present
Bleeding increased since 2 yrs
PAST HISTORY:
Episode of fever 14 days back after taking COVID vaccine, after which she had vomitings for 4 days 4-5 episodes/day ,visited rmp took medications and was fine
5 months back she c/o giddiness and she visited RMP where she was diagnosed of low BP
There is no history of Diabetes, hypertension,asthma , tuberculosis.
PERSONAL HISTORY:
Diet - mixed
Appetite - decreased since 5 days.
Sleep - adequate
Bowel and bladder- regular
Addictions - no addictions
Allergies - None
FAMILY HISTORY:
There is no significant family history
GENERAL EXAMINATION:
Pateint is conscious , coherent , cooperative.
Moderately built and moderately nourished.
#Pallor - present
No Icterus
No cyanosis
No clubbing
#Cervical lymphadenopathy present
No bilateral pedal edema
VITALS
Temperature - febrile
Pulse rate -82 BPM
Blood pressure -90/60 mm of Hg
Respiratory rate - 16 cpm
EXAMINATION OF NECK
On Inspection : A diffuse swelling is noticed on the anterior neck region which is moving on swallowing.
On Palpation, Diffuse swelling is present which is firm in consistency
Lower margin is palpable.
On palpation of lymph nodes , multiple cervical lymph node enlargement is seen bilaterally at level of posterior triangle.
Swelling is tender, smooth ,mobile, firm in consistency.
SYSTEMIC EXAMINATION:
CVS - S1 , S2 heart sounds heard
no murmurs
RESPIRATORY SYSTEM -bilateral air entry present
Normal vesicular breath sounds heard
ABDOMEN - soft and non tender
Bowel sounds are heard
No organomegaly
CNS- intact
No signs of meningeal irritation
INVESTIGATIONS :
20/10/21 :
HAEMOGRAM :
#Hb : 7.2gm/dl
PACKED CELL VOLUME
#TSH : 5.94
Impression : 1. Diffuse thyroid disease most likely thyroiditis.
2. Cervical lymphadenopathy
PROVISIONAL DIAGNOSIS :
Cervical lymphadenopathy with thyroiditis
On 21.10.2021.
Tab .RENERVE-P 75 mg 2 times a day
Tab .DOlO 650 mg 3 times a day
Tab .ZOFER 4 mg PO/OD
Tab .ULTRACET 1/2 tab QID
Plenty of oral fluids
On 22.10.2021
Tab.PCM 500 mg /PO / TID
IVF normal saline and ringers lactate -50 ml / hr.
Tab.OROFER/ PO/ BD
Oral fluids
Tab . ULTRACET 4 times a day for 3 days
Inj .MONOCEF 1 gm /IV / BD
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