32 yr old female with throat pain
MEDICINE CASE DISCUSSION
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M Rambai ,9th semester
Roll number 78
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 , agriculture by occupation,resident of kattangur came with chief complaints of fever with chills since 4 days admitted on 20.10.2021.
Body pains since 4 days
Throat pain since 4 days
Neck pain since 4 days
Vomitings since 2 days
Shortness of breath since 2 days
Giddiness since 2 days
Palpitations since 1 day
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 14 days back,then she has taken her covid vaccine ,later she developed fever after 2 days which is of high grade, associated with vomitings which is of 4 episodes per day .
She went to local RMP ,took medication and fever subsided.
She again had fever 4 days back which is of high grade, continuous type of fever and associated with chills and rigours
There is history of nocturnal variation( fever increased during night times)
Patient has history of body pains since 4 days
There is history of headache which is of diffuse type associated with nausea.
She also has palpitations since 2 days ,more during morning times
Patient has a history of throat pain with difficulty in swallowing since 4 days
She also has neck pain since 4 days
Pateint has history of shortness of breath since 2 days
Patient has history of vomitings which is of 3 episodes per day since 3 days which is of non bilious and non projectile.
She initially used to go for field works ,but as she started developing shortness of breath and body pains,throat pain she couldn't go to work and even she even complained of easy fatiguability .
Her condition worsened more during evening times( she had body pains more during evening)
She also has a history of hair loss since 3 years
Weight loss since 3 years
No history of cold / heat intolerance
No history of bowel irregularities
No history of menstrual irregularities
PAST HISTORY
There is no history of Diabetes, hypertension,asthma , tuberculosis.
PERSONAL HISTORY:
Diet - mixed
Appetite - normal
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 and well oriented to time,place and person .
Moderately built and moderately nourished.
pallor - present
No Icterus
No cyanosis
No clubbing
No lymphadenopathy
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 slight swelling is noticed on the neck region which is movable on swallowing.
On palpation , multiple cervical lymphadenopathy is seen
Swelling is smooth ,mobile,firm in constiency.
SYSTEMIC EXAMINATION
CVS - S1 , S2 heart sounds heard,no murmurs
RESPIRATORY SYSTEM -bilateral air entry present
ABDOMEN - soft and non tender
Bowel sounds are heard
No organomegaly
CNS- intact
No signs of meningeal irritation
INVESTIGATIONS
HAEMOGRAM
PACKED CELL VOLUME
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