A 36yr old Female with Fever and SOB

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. 


18/08/2022

Blog by Aruna.J
Roll no 61.

A 36 year old female who is a resident of Narketpalli housewife by occupation came with chief complaints of 
1. Fever since 7 days 
2. SOB since 4 days 


HOPI - 
Patient was apparently asymptomatic 7 days back then she developed fever on 9th of August which was intermittent in nature, associated with headache, chills and rigors . Also she has complaints of pins and needle like sensation on the left side of her body . ( went through mastectomy of left breast) 

Then since Friday she has SOB after having any meal.  ( grade 3 ) 

And had 4 episodes of vomiting which had food contents , non projectile, non bilious. 

PAST HISTORY- 
No history of Diabetes , Hypertension, thyroid abnormality, epilepsy, CAD , TB 

FAMILY HISTORY- fathers sister has blood cancer . 

SURGICAL HISTORY- 
Mastectomy-left breast 

DRUG HISTORY- no drug allergies 

PERSONAL HISTORY- 
Appetite- normal 
Diet - mixed 
Sleep- inadequate since fever 
B&B - regular 
Addictions- none 

GENERAL EXAMINATION- 
Patient is conscious, coherent and cooperative. 
Moderately  built and moderately nourished. 
Pallor- present 
Icterus- absent 
Cyanosis- absent 
Clubbing- absent 
Lymphadenopathy- cervical lymph nodes
 enlargement 
Edema- mild pedal Edema 

VITALS - 

BP - 100/70 mm of Hg

RR - 30 cpm

Temperature- mild fever ( 

PR - 98 bpm


SYSTEMIC EXAMINATION- 


Cardiovascular system  

JVP - not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent


Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS


Abdomen examination:

INSPECTION

Shape : scaphoid 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard


CNS examination: 

No focal neurological deficit’s 


PROVISIONAL DIAGNOSIS: 

Fever with cervical lymphadenopathy 


INVESTIGATIONS:


USG - 



ECG:

Labs-


TREATMENT: 
Inj. Neomol 1gm/ iv / stat 
Inj Iron sucrose 200mg in 100 ml NS / iv / OD
Inj PAN 40mg / iv / OD 
Inj Optineuron lamp 100 mg / iv / OD
Monitoring vitals. 





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