1801006056 SHORT CASE

 March 16 ,2023

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I have 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 and treatment plan

Blog by Janhavi Virani 

A 35 year old female resident of Nakrikal who is a daily wage labourer by occupation came with 

CHIEF COMPLAINTS of :- 

1. Fever since 1 week 

2. Headache since 1 week 

HOPI :- 

Patient was apparently asymptomatic 1 week back then she developed fever which is intermittent in onset ( on and off ) increasing at night time and decreasing in the morning associated with chills and headache ( increased headache leading to increase in fever ).

 Fever is relieved by taking anti pyretic . No history of nausea , vomiting , rash or body pain . 

History of unilateral headache since 1 week which is severe throbbing pain in left fronto parietal occipital region  radiating to the neck due to exposure of stress . Pain is causing her to wake up at night ( inadequate sleep ) . 

Headache is associated with vomiting ( just 1 episode ) phonophobia and blurring of vision ( history of change in spectacles) , decreased regular physical activity , tingling sensation in hand and feet . It relieves on taking rest and medication .

 No history of aura , photophobia , depression , irritability, cravings , diarrhoea/constipation. 

She has history of burning micturition since 5 days associated with decreased urine output, decreased frequency, left loin pain which is dragging type pain ( since 1 day ) . No aggrevating and relieving factors . No history of urgency, hematuria , nausea , vomiting . 

DAILY ROUTINE:- 

She gets up at at around 5 in the morning does her daily chores and gets her kids ready for school then she has breakfast at 8:30 or 9 am and then sleeps for sometime before she goes to work which she has stopped going since  6 years . 

PAST HISTORY:- 

Similar episode one year back . 

Not a known case of Diabetes, hypertension, epilepsy, cardiovascular disease and tuberculosis. 

History of hypothyroidism 10 years back for which she is on daily thyroxine ( 75 mg ) supplements. 

History of renal stones in the left kidney 6 years back for which she took conservative treatment. 

FAMILY HISTORY :- 

No significant family history . 

PERSONAL HISTORY:- 

Diet - mixed 

Appetite - decreased 

Sleep- inadequate 

B&B - she is constipated 

Addictions- none 

NO H/o is any drug allergy 

GENERAL EXAMINATION:- 

Patient is conscious, coherent and cooperative 

Well oriented to time.  Place and person . 

Moderately built and nourished 

O/E - thyroid appears normal 

                       Clubbed- absent 

                       Cyanosis- absent

                      Icterus - absent

           Pallor - present

           Generalised lymphadenopathy- absent 

           Edema - absent

          

           FEVER CHART :- 

        

VITALS:- 

Temp - 99 F 

PR - 84bpm

RR- 20 cpm

BP - 100/70 mm of Hg 

SYSTEMIC EXAMINATION:-  

CVS - S1 S2 heard  , no murmurs present 

RESP - bilateral Air entry present

 normal vesicular breath sounds heard 

ABDOMINAL- 

examination of oral cavity is normal 

**Inspection

-shape-normal(rounded)

-no flank fullness is seen.

-skin-no scars seen ,presence of striae.

-no dilated veins seen 

-Movements of abdominal wall-no visible peristalsis,no visible pulsations

-umbilicus-inverted.

**Palpation

-tenderness-hypogastrium and left lumbar region

-warmth- present (fever)

-rigidity,guarding is absent

*no organomegaly, normal bowel sounds heard

CNS:no focal deficits are found. 

Higher mental functions- normal 

Brudzinski’s sign - absent 

Kernig’s sign - absent 

PROVISIONAL DIAGNOSIS:- 

Migraine/ Left Renal Calculi / UTI 

INVESTIGATIONS:- 

            

            Complete urine examination:- 

            

            Hemogram :- 

            Thyroid profiles :- 

           USG :- 

           

            

TREATMENT:- 

Inj-optineuron 1amp in 100ml of NS OD

IvF-@70ml/hr

Tab nitrofurantoin 100mg

Tab pan

Tab naproxen  250mg

Bp,temp,RR,PR check 4th hrly

Tab thyronorm  25mcg