14 YEAR OLD FEMALE WITH FEVER

 SUDHAMSHI REDDY

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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 diagnosis 

This is a case of a 14 year old girl who came with chief complaints of:

1. Cough since 7 days

2. Fever since 5 days, vomiting 5 days ago

3. Lower back ache since 1 month on and off

4. Pain during micturition

5. Generalised weakness and body pains

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 7 days ago, then she developed -

Cough insidious in onset and gradually progressive. Initially dry cough, later progressed to productive cough with no diurnal or seasonal variations.

 

Fever since 5 days, high grade associated with chills and rigours, relieved with medications, no aggravating factors. 

Vomiting- 5 days ago of 2-3 episodes, with food as content.

Lower backache since 1 month. Generalised weakness and body pains are present.

Pain during micturition in the lower abdomen. No burning micturition. History of increased frequency of micturition. 

Passing stools every 3 days. No history of weight loss.

PAST HISTORY:

History of similar complaints 2 years back , got admitted then.

In June 2021, she came with complaints of abdominal pain and vomiting for 6 days.

She was apparently asymptomatic 6 days back, later developed abdominal pain, sudden in onset, diffuse, dragging type, non radiating which relieves on rest, not aggravated on food intake.

Vomiting for 5 days, 2episodes/day, non projectile, non bilious, non blood stained, with food as content.

H/O decreased urine output for 6 days associated with burning micturition.

H/O loose stools for 2 days, 3-4 episodes/day, watery, yellowish, mucoid, non foul smelling

H/O fever for 2 days, relived on medication.

Child was admitted in PICU with above complaints and all necessary Investigations were done and was  given symptomatic treatment with

INJ CEFOTAXIME

INJ PANTOP

INJ ZOFER

TAB SPOROLAC 

SYRUP ZINCOVIT

-History of acute nephritis 4 years ago.

PERSONAL HISTORY

She is an 8th class student

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder regular

Menarche not attained

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative. Well oriented to time place and person. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

VITALS:

Pulse - 98 bpm

BP - 120/80 mm Hg

RR - 18 cpm

Temp- 96.6 F

SpO2- 98% on room air

GRBS- 94 mg%

SYSTEMIC EXAMINATION:

RS: BAE ,NVBS, no added sounds

CVS : S1 ,S2 heard no murmurs

P/A : soft , non tender

CNS:

HIGHER MENTAL FUNCTIONS- INTACT

MEMORY- able to recognise her family members and recall recent events

SPEECH: normal

CRANIAL NERVE EXAMINATION- normal

REFLEXES-

                      RIGHT          LEFT

BICEPS            3+                 3+

TRICEPS          2+                 2+

SUPINATOR     1+                1+ 

KNEE                2+                2+

ANKLE.            2+                 2+

SUPERFICIAL AND DEEP REFLEXES ARE PRESENT AND NORMAL

MUSCLE POWER- 

                                    RIGHT           LEFT 

UPPER LIMB  

ELBOW                         5/5                  5/5 

WRIST                           5/5                  5/5 

HAND GRIP                  5/5                  5/5

LOWER LIMB 

HIP                                   5/5                 5/5 

KNEE.                              5/5                 5/5 

ANKLE                            5/5                 5/5

TONE- NORMAL IN UPPER AND LOWER LIMBS

NO INVOLUNTARY MOVEMENTS

SENSORY SYSTEM- ALL SENSATIONS ARE NORMAL

Referred to dermatology I/V/O itching all over the body, was diagnosed as scabies and adviced

1. PERMETHRIN 5% LOTION LA ON DAY1, DAY 8

2. Tab. TECZINE 5mg SOS.

INVESTIGATIONS:

Hemogram:

2/4/23

Hb-12.3gm/dl

TLC-5300cells/cu.mm

PLT- 3.95 lakhs/cu.mm

RBC- 4.45

3/4/23

Hb- 12.2gm/dl

TLC-7600 cells/cu.mm

PLT- 4.08 lakhs/cu.mm

RBC- 4.37

4/4/23

Hb- 12.5gm/dl

TLC- 6800 cells/cu.mm

PLT- 4.4 lakhs/cu.mm

RBC- 4.57

CUE:

Albumin- nil

Pus cells- 2-3

Epithelial cells- 2-3

MP strip test- negative

NS1 antigen- negative

WIDAL test- negative

Urine for C/S- No growth

Blood for C/S- No growth after 24hrs of aerobic incubation.

Sputum for C/S- Normal oropharyngeal flora grown.

USG ABDOMEN-

CHEST X -RAY

 

FEVER CHARTING-

PROVISIONAL DIAGNOSIS:

VIRAL PYREXIA WITH CHRONIC CYSTITIS

TREATMENT:

1.TAB PCM 500mg PO/SOS

2. SYP ASCORIL LS PO/ TID

3. SYP CITRALKA 10ml PO/TID in 1 glass of water

4. PERMETHRIN 5% LOTION LA

5. TAB TECZINE 5mg PO/SOS