A 36 year old female with fever and SOB

 A 36 year old female, homemaker from Narketpally was presented to the hospital with

C/o Shortness of breath since 4 days

History of presenting illness

Patient was apparently asymptomatic 7 days back then she developed fever with chills and rigor (9th August 2022) which was intermittent, subsided on taking medication but increased within 30-60 mins.

Fever was associated with headache and sensation of pins and needles on the left side from head to toe. 

She visited a local doctor and was diagnosed to have typhoid for which she was taking medication. 

She developed shortness of breath 4 days back(12th August 2022) which was of grade 3.

She had 4-5 episodes of vomiting three days back(13th August 2022) which was non projectile, non bilious and contained food particles of immediately previous meal. 


Past history

H/o of left mastectomy 2 years back on suspicion of malignancy. 












H/o Renal calculi 7 years back

No h/o Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, CAD. 


Personal history

Appetite - Normal

Diet - Mixed

Sleep - Inadequate since the day of fever

Bowel and bladder movements - Regular

Has few disturbances in bladder movements since few years

Addictions - None


Family history - No similar complaints in the family. 


Drug history - Not significant


General physical examination

Patient is conscious, coherent, cooperative

Well oriented to time, place and person

Well built and well nourished

Pallor is present 



Bilateral Pedal edema present pitting type. 

Cervical lymphadenopathy present. 

No icterus, cyanosis, clubbing, generalized lymphadenopathy. 

Virals

Temperature - Febrile


Pulse - 98bpm

Respiratory rate - 30cpm

Blood pressure - 100/70 mmHg

SpO2 - 97% at Room atmosphere

GRBS - 110 mg%

Systemic examination 

Respiratory system - Shortness of breath grade 3, BAE present. Pain in the left last intercoastal area while inspiring

CVS - S1, S2 heard. 

Abdomen - Soft, non tender.

CNS - No focal neurological deficits

Reflexes                   Right               Left

Biceps                        ++                    ++

Triceps                       ++                    ++

Elbow                         ++                    ++

Wrist                           ++                    ++

Knee                            ++                    ++

Ankle                          ++                     ++

Plantar                       flexor             flexor


Provisional diagnosis

Fever with lymphadenopathy under evaluation

Investigations

Hemogram shows Hb of 6.4mg/dL, PCV 21.8,TLC 9,100.

Serum electrolytes normal

USG neck shows B/L Lymphadenopathy of level I, II


ECG


Treatment

Inj. Neomol 1gm IV stat

Inj. Iron sucrose 200mg in 100ml NS IV OD every alternate day

Inj. Pantop 40mg IV 

Inj. Optineuron 1amp in 100ml NS













Comments

Post a Comment

Popular posts from this blog

A 28 year old male with Gross Ascites

Image
 This is an 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. A 28 year came to OPD with C/o Abdominal distention since 10 days        Abdominal discomfort since 10 days History of Presenting illness  Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort and distention of abdomen for which he visited a primary health care centre near his residence where he was adviced to get an Xray of Abdomen for which he visited our Institution. Abdominal distention was insidious in onset and gradually progressed to current size  Patient
Read more

60 year old male with trunkal obesity with URTI, HFMEF, DM, HTN

Image
A 60 year old male came to casuality with C/o Cough, cold since 3 days         Chest pain since 1 day         Fever since 1 day HOPI Patient was apparently asymptomatic 3 days ago then he developed cough with sputum, scanty in quantity, green in color associated with cold and nasal blockage H/o Fever, low grade, continuous non aggravating and no relieving factors No h/o rash, retroorbital pain, arthralgia C/o chest pain, diffuse, squeezing type associated and aggrevating with cough, non relieving  No h/o abdominal pain, vomiting, diarrhea  No h/o seizures, tremors Past history : K/c/o DM, HTN since 10 years and on unkown medication  N/k/c/o Asthma, CAD, CVA, Thyroid disorders, Epilepsy General examination  Pt is C/C/C No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema Vitals Temperature - 100.8°F PR - 104 bpm BP - 110/70 mmHg RR - 22 cpm SpO2 - 93 @ 4L O2 GRBS - 301 mg% Systemic Examination CVS - S1,S2 heard RS - BAE present  CNS - NFND P/A - Soft, Non tender Investigations on admiss
Read more

39 year old male patient with Altered sensorium and Paraplegia

Image
A 39 year old male patient resident of Nalgonda, electrician by occupation was presented to the casualty on 9th of November,2021 As informed by his attenders C/o decreased responsiveness, loss of appetite and decreased speech since 2 days before admission and completely couldn't talk on the day of admission.  History of presenting illness   Patient was apparently asymptomatic 8months ago then he developed pain abdomen and intermittent low back pain and dribbling of urine so he visited a physician and was told to have renal stones and meatal stenosis for which he underwent urethral dilatation in July, 2021.  He was incidentally detected to have serum creatinine 5g/dL while visiting a hospital in Nalgonda. His urine output was good and he had no pedal edema or sob. He was told to have renal failure and was on medication since then. He had h/o weight loss and loss of appetite and low grade fever.  He was having intermittent back pain since then After 2 months, in the last week of Aug
Read more