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14 year old Female with fever

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.


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



ULTRASOUND 


COMPLETE URINE EXAM




HEMOGRAM






BLOOD FOR MP STRIP TEST









WIDAL TEST






DENGUE NS1 ANTIGEN, IGG AND IGM



SERUM CREATININE




TREATMENT:
1-4-2023
1. Tab Paracetamol 500 mg po tid
2. Syrup Ascoril LS 5 ml po tid












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