30yr Female with Fever and Breathlessness

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

PRESENTING COMPLAINTS:

Fever since 15days

Breathlessness since 10days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4months back then she developed fever on and off , decreased appetite. Now since 15days patient is having fever high grade, continuous type, relieved on medication.

Associated with chills and rigor.

Associated with dry cough (since 10days)

Breathlessness since 10days, Grade-III, insidious onset, gradually progressive, aggravates on exertion.

No H/O vomitings, headache, burning micturation 

No H/O chest pain, excessive sweating 

HISTORY OF PAST ILLNESS:

Not K/C/O DM,HTN,TB,CAD,Asthma,Epilepsy 

PERSONAL HISTORY:

Diet- Mixed

Appetite- Lost since 4months

Sleep- Adequate 

Bowel and bladder movements- Regular 

No Addictions 

No known Allergies 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

Patient is concious, coherent, co-operative

No Pallor, Icterus, Cyanosis, Clubbing,Lymphadenopathy,Edema.

Vitals:

BP- 110/70mmhg

PR- 80bpm

RR- 16cpm

SpO2- 96% at room air 

GRBS- 102mg/dl

Per Abdomen:

Inspection:- no scars seen.

Palpation:- No tenderness is present.

Percussion:- No free fluid.

Auscultation:- Bowel sounds heard.

SYSTEMIC EXAMINATION:

Respiratory system:-

Upper Respiratory tract examination:

Nostrils- normal 

Nasal septum- no deviation 

No nasal polyps 

No Tonsils 

Posterior pharyngeal wall- normal 

Lower Respiratory tract examination:

Inspection:

Shape of the chest - Circular

Movement of chest- appears to be equal on both sides

Trachea- appears to be in central position 

Apex beat- visible 

No scars and sinuses seen

Palpation:

Trachea- Central in position 

Apex beat- shifted to left 

Increased vocal fremitus

No rib crowding 

Percussion:

                                     Right                         Left

Supra clavicular         Resonant                 Resonant 

Clavicular                  Resonant                  Resonant 

Infra clavicular           Resonant                 Resonant 

Mammary                  Resonant                  Resonant 

Axillary                      Resonant                 Resonant 

Infra axillary              Resonant                 Resonant 

Supar scapular              Resonant                   Resonant 

Inter Scapular              Resonant                    Resonant

Infra scapular               Resonant.                    Resonant 

Auscultation:

BAE +

Normal vesicular breath sounds 

No wheeze 

?Tubular sounds in left mammary area 

CVS:

S1,S2 heard 

No murmurs 

CNS :

No focal and neurological deficits

HMF -Normal

Pupils- Bilateral PSNL

                      Upper limb                        Lower limb

               Right             Left                  Right          Left

Tone:      Normal        Normal            Normal      Normal

Power:           5/5           5/5                   5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                  +

Plantar         Flexion        Flexion

INVESTIGATIONS:

CHEST X-RAY:

ECG:

PROVISIONAL DIAGNOSIS:

Left Upper Lobe Pneumonia with right sided fibrosis;

Pulmonary Koch’s (Sputum-positive for TB)

TREATMENT:

IV Fluids (NS,RL) with Optineuron  @75ml/hr

Nebulisation with Duolin 8hrly, Budecort 12hrly

INJ. PIPTAZ 4.5g IV/TID

TAB. AZITHROMYCIN 500mg PO/OD

INJ. PAN 40mg IV/OD BBF

INJ. NEOMOL 1g IV/SOS (if temperature >101F)

TAB. DOLO 650mg PO/SOS

BP,PR,Temperature,RR charting 4hrly. 

GRBS charting 6hrly.