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GM Case 8 12/09/23 - 60F with headache since 1 month and fever with productive cough since 10 days

Hi, I am P.Kathyayani,5th sem medical student. This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 


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 a diagnosis and treatment plan.  


CONSENT AND DE-IDENTIFICATION : 

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 throughout this piece of work whatsoever.





Chief complaints:
A 60 year old female resident of Suryapet,daily wage laborer by occupation came to OPD with chief complaints of
Headache since 1 month
Fever since 10 days
Cough since 10 days 



HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month ago then she developed headache localised to parietal region radiating to neck and lower back  associated with cold, productive cough aggravated by exposure to cold weather,sputum is white and mucoid in nature.
Fever-high grade associated with chills and rigors, intermittent,no diurnal variation.

No chest pain,no orthopena,no PND, no SOB, no sweating,no palpitations,no nausea and vomiting.



12/09/23 - 60F with headache since 1 month and fever with productive cough since 10 days

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Hi, I am Manasvi Peddineni, 5th sem medical student. This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 
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 throughout this piece of work whatsoever.

Chief Complaint:
60 Year old female, resident of Suryapet, daily wage laborer by occupation came to OPD with chief complaints of
- headache since 1 month
- fever since 10 days
- cough since 10 days.

History of Present Illness:
Patient was apparently asymptomatic 1 year ago when she developed shortness of breath of grade 1, no orthopnea, no PND, no chest pain.
She had headache since 1 month, of diffuse type in the parietal region which radiates to neck and lower back.
It was associated with productive cough since 10 days, aggravated by exposure to cold weather, not relieved by medication, no diurnal variation, and the sputum is white in colour and mucoid in nature. 
She also has fever since 10 days of high grade, associated with chills and rigor, no sweating, intermittent, no diurnal variations.
No h/o chest pain, sweating, palpitations, loose stools, nausea, vomiting, burning micturition, decreased urine output and weight loss.

Daily Routine: 
Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.
After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.



PAST HISTORY:
Similar complaints of fever, headache,body pains 2 months ago which was relieved on medication.
Not a k/c/o DM, HTN, CAD, TB, epilepsy. 

SURGICAL HISTORY:
Hysterectomy was done 20 years ago



PERSONAL HISTORY:
Married
Mixed diet
Decreased appetite
Inadequate sleep
Normal micturition 
Bowel and bladder movements regular
Addictions--Toddy drinker stopped 20 years ago
No known allergies 





FAMILY HISTORY:
No significant family history 



DRUG HISTORY:



GENERAL EXAMINATION:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
Pallor present
No icterus
No cyanosis
Clubbing of fingers present
No lymphadenopathy
No pedal edema



VITALS:
Temperature: 95 ⁰F

Pulse:88 beats per minute

Respiratory rate: 20 cycles per minute

Blood pressure: 130/70 mm of Hg

SPO2:98%

Fever chart
TPR graphic sheet:


SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

 upper respiratory tract : oral cavity, nose & oropharynx appear normal

chest is bilaterally symmetrical  

respiratory movements appear equal on both sides and of thoracoabdominal type

position of trachea : central

vesicular breath sounds : present

wheeze present in bilateral suprascapular, infrascapular and mammary areas

CARDIOVASCULAR SYSTEM:

Inspection :

shape of chest : elliptical

no engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

no cardiac thrills 

Auscultation : 

S1,S2 are heard

no murmur

ABDOMEN:

shape: scaphoid
no tenderness
no palpable mass
no bruits
no free fluid
hernias orifices: normal
liver: not palpable 
spleen : not palpable
no bowel sounds


CENTRAL NERVOUS SYSTEM:
conscious 
normal speech
no neck stiffness
no Kerning's sign
cranial nerves: normal
sensory : normal
motor: normal
reflexes: all present bilaterally
finger nose in coordination: not seen 
knee heel in coordination: not seen
gait: normal

INVESTIGATIONS:

X Ray - 


ECG:


Biochemical investigations:
Hemogram:
Blood test for Malaria Parasite:
Bacterial culture and sensitivity report:



PROVISIONAL DIAGNOSIS:
Pyrexia secondry to lower respiratory tract infection with h/o of bronchial asthma

Treatment:

TAB. Azithromycin
TAB. Amoxiclav
TAB. N.Acetylcysteine
TAB.Monteleukast
TAB. Paracetamol 650mg
SYRUP.Ascoril-LS



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