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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.Thisnt plan.
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 micturation
5. generalised weakness and body pain
HISTORY OF PRESENTING ILNESS:
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. 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.
Lower Bach ache since since 1 month. Generalise 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
There is history of similar complaints 2 years and got admitted then.
In June 2021, she came with complaints of abdominal pain and vomiting since 6 days.
was apparently asymptomatic 6 days back, later developed abdominal pain, sudden in onset, diffuse, dragging type, non radiating which relieves on rest, Non radiating Not aggravated on food intake.
Vomittings since 5 days, 2episodes/day, non projectile, non bilious, non blood stained, content-food particles
H/O decreased urine output since 6 days associated with burning micturition.
H/O loose stools for 2 days, 4days back 3-4 episodes/day, watery, yellowish, mucoid, non foul smelling
H/O fever for 2 days, 4 days back, relived on medication
no H/O cough, cold, ear discharge, reddish discolouration of urine,
no H/O blood worms in stools
Child was admitted in PICU with above complaints and all necessary Investigations were done Child was given symptomatic treatment with
INJ CEFOTAXIME,INJ PANTOP,INJ ZOFER, TAB SPOROLAC and SYRUP ZINCONIA
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 count
Temp- 96.6 oC
SpO2- 98%
GRBS- 94 mg%
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Respiratory system:
Bilateral air entry is present
Normal vesicular breath sounds are heard.
Per Abdomen:
Shape is scaphoid
Abdomen is soft and non tender with no signs of organomegaly
Bowel sounds are heard
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
PROVISIONAL DIAGNOSIS:
Viral pyrexia
Chronic cystitis
INVESTIGATIONS
CHEST X-RAY
COMPLETE URINE EXAM
HEMOGRAM
BLOOD FOR MP STRIP TEST
WIDAL TEST
DENGUE NS1 ANTIGEN, IGG AND IGM
TREATMENT:
1-4-2023
1. Tab Paracetamol 500 mg po tid
2. Syrup Ascoril LS 5 ml po tid
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