24Y F with Fever and SOB
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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.
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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
This is a case of 24 year old female came with
C/o fever since 5 days
C/o sob since 5 days
HOPI
Patient was apparently alright 5days back then she had fever which is insidious onset gradually progressive,low grade, intermittent and relieved by medication.
Sob since 5 days on exertion Grade 2.No orthopnea,no PND.No pedal edema.seasonal variation present more during winter season.
No cough/cold.
No abdominal pain, vomitings.
No H/o burning micturition.
No H/o chest pain, palpitations.
H/o similar complaints one year back sob and cough and visited hospital and took medication. Similar episodes once every 2-3 months more during winter.
3 months back she had severe sob and cough in the midnight and went to local hospital and used nebulization. since 3 she is having intermittent episodes and relieved with nebulization.
K/c/o pcod since 1yr.
N/k/c/o HTN,DM, Thyroid , epilepsy
Personal history:
Diet: mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder: Regular
No addictions and allergic to dust.
GENERAL EXAMINATION:
Vitals:
BP 120/80 MMHG
PR 92 BPM
RR 20/MIN
GRBS 93 MG/DL
SpO2 99% ON RA
No pallor,No icterus, cyanosis, clubbing, lymphadenopathy.
SYSTEMIC EXAMINATION ::
GIT
INSPECTION :
Abdomen - scaphoid
Umbilicus - inverted
Movements - all quadrants are equally moving with respiration
No scars and sinuses
No visible peristalsis
No engorged veins.
PALPATION:
No local rise in temperature and no tenderness in all quadrants
LIVER: no hepatomegly
SPLEEN- not enlarged
KIDNEYS - bimanual palpable kidneys
PERCUSSION :
no shifting dullness
AUSCULTATION :
Bowel sounds are heard and are normal
No bruit
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Bilateral Airway entry - present
Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.
Palpation: all pulses felt , apex beat felt.
Percussion: heart borders normal.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
Central Nervous system:
Higher motor functions- Intact
Speech: Normal
Cranial nerve functions - Normal
Sensory system-Normal
Motor system Right Left
Power- UL 4/5 4/5
LL 4/5 4/5
Neck Normal
Trunk muscles Normal
Tone- UL Normal Normal
LL Normal Normal
Reflexes-
Superficial reflexes - Intact
Plantar flexion flexion
Deep tendon reflexes -
Biceps ++ + +
Triceps ++ ++
Supinator ++ ++
Knee ++ + +
Ankle ++ + +
INVESTIGATIONS:
USG(6/5/23)
DIAGNOSIS :
Bronchial Asthma with PCOS
TREATMENT:
1. Tab.PCM 650 mg po/TID
2. Nebulization with Ipravent 6th hrly
budecort - 12 th hrly
3.Tab.Pantop 40 PO/BD/BBF
Bronchial Asthma with PCOS
24 year old female came with
C/o fever since 5 days
C/o sob since 5 days
Patient was apparently alright 5days back then she had fever which is insidious onset gradually progressive,low grade, intermittent and relieved by medication.
SOB since 5 days on exertion Grade 2.No orthopnea,no PND.No pedal edema.seasonal variation present more during winter season.
No cough/cold.
No abdominal pain, vomitings.
No H/o burning micturition.
No H/o chest pain, palpitations.
H/o similar complaints one year back sob and cough and visited hospital and took medication. Similar episodes once every 2-3 months more during winter.
3 months back she had severe sob and cough in the midnight and went to local hospital and used nebulization. since 3 she is having intermittent episodes and relieved with nebulization.
K/c/o pcod since 1yr.
Course in hospital :
Patient was investigated further and OBG referral was done I/V/O PCOS morphology in both the ovaries and was advised further investigations (serum prolactin and TFT)and advised life style modifications and regular exercise.
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