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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
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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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
A 13 year old female patient from Eeduluru came to OPD with the following
Chief complaints:
Fever and weakness since 1 week
cold since 1 week
cough since 1 week
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 week ago then she developed fever which is insidious on onset , no progression , high grade fever , associated with chills and rigors , no aggregating factors , relived temporarily on medication , increased during night
Later she developed cough which is dry and not associated with chest pain , non blood tinged , relived on medication , no aggrevating factors. Then she developed cold 1 week ago insidious in onset , aggregated during fever episode , relieved on medication
Generalised body aches and weakness during fever episode
No h/o vomitings , headache , burning micturition , nausea
No h/o odynophagea, dysphagia, diarrhoea
PAST HISTORY
Not a known case of hypertension, diabetes, epilepsy , tuberculosis
Menarche - not attained
PERSONAL HISTORY
Mixed diet
Regular bowel and bladder movements
Inadequate sleep due to increase in fever in the nights
No addictions
No allergies
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
Patient is conscious , coherent , cooperative
Moderately built , moderately nourished
No signs of pallor , icterus , cyanosis , clubbing , Kolinychia, lymphadenopathy
Vitals
BP- 120/80 mmhg
Pulse rate - 86 bpm
RR - 13 cpm
Temperature- afebrile
SYSTEMIC EXAMINATION
CVS
INSPECTION
Position of trachea is appears to be central
No chest wall abnormalities
Apical impulse is seen
No visible pulsations , dilated engorged veins , surgical scars , sinuses
PALPATION
Confirmed inspection findings
Position of trachea was central
Apex beat was localised in the 5th intercostal space 2 cms medial to mid clavicles line
No parasternal heave , thrills , tender points
AUSCULATION
S1 , s2 are heard
Apex beat heard
No added sounds
No murmurs heard
Bilateral air entry is present
Normal vesicular breath sounds are heard
Abdomen is soft , non tender
No signs of organomegaly
Bowel sounds are heard
CNS
No focal deficits
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Viral Pyrexia with neutropenia ( under evaluation).
TREATMENT
Iv fluids 50ml/hr @ n
Tab pcm 500 mg
Syrup ascoril - ls 10 ml po/tid
Inj. Cefipime 500 mg iv / tid
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