A 14 year old girl presented with fever and cough

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I have been given this case 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.

A 14 year girl who is a resident of Chinnathummala came with chief complaints of 

 

CHIEF COMPLAINTS :

- Fever for 3 days 5 days back

- Cough with sputum since yesterday 

HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal 7 days back then she developed low grade fever for 3 days which increased at night not associated with chills and rigors. Then she went to a private hospital and found to have low Haemoglobin( 3.38 gm/dl) and platelet count.

- After 5 days she had cough with sputum white in colour non blood stained since yesterday night

- No H/o Nausea, Vomiting, weight loss, Abdominal pain, Giddiness, Headache.

PAST HISTORY :

Diabetes - No

Hypertension - No

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - No

FAMILY HISTORY : Nil significant 

MENSTRUAL HISTORY:

Age of menarche - 12 years

Cycles are regular, 30 days cycle

Flow is Normal ( 5 days ), 2-3 pads per day

Not associated with pain and clots

PERSONEL HISTORY :

Occupation - Student(7th class)

Diet - Mixed    

Appetite - Normal

Bowel and bladder movements - Regular

Allergies - No

Addictions - No

GENERAL EXAMINATION :

Temperature - Afebrile   

Pulse - 77 beats/min

BP - 120/90 mmHg

RR - cycles/min

GRBS - 106 mg%

SPO2 - 100 %

Pallor - Present 

Icterus - No 

Clubbing - No

Cyanosis - No

Lymphadenopathy - No

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular

ABDOMEN :

Shape - Scaphoid

No Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard

CNS : Normal

Patient is Consious, Coherent, Well oriented to time place and surroundings.

INVESTIGATIONS :

25/8/22:

Blood grouping and Rh typing- O positive 

Haemogram -

26/8/22 :

Random blood sugar - 91 mg/dl

Blood urea - 15 mg/dl

CRP - Negative 

ESR - 85 mm 1st hour

LDH - 212 IU/L

Reticulocyte count - 0.9 %

Serum Creatinine - 0.4 mg/dl

Serum iron - 64 ug/dl

CUE -

LFT -

Serum Electrolytes -

28/8/22 :

Haemogram -

29/8/22 :

Haemogram -

PROVISIONAL DIAGNOSIS :

Severe Anaemia with decreased evaluation.

TREATMENT :

27/8/22 -

Monitor vitals 

Inj Optineuron in 100 ml NS over 30 min IV/OD

O/E : Patient is c/c/c

BP - 100/70 mmHg

PR- 80 bpm

RR- 18 cpm

SPO2 - 100% on RA

CVS - S1,S2 Heard

R/S - BAE +

P/A - Soft, Non tender.

28/8/22 -

Monitor vitals 

Inj Optineuron in 100 ml NS over 30 min IV/OD

Inj Iron sucrose 200 mg/IV in 100ml NS slow over 1 hour

O/E : Patient is c/c/c

BP - 100/70 mmHg

PR- 70 bpm

RR- 14 cpm

Temp - 97°F

CVS - S1,S2 Heard

R/S - BAE +

P/A - Soft, Non tender.

29/8/22 -

Monitor vitals 

Inj Iron Sucrose 100mg in 100ml NS alternate day

O/E : Patient is c/c/c

BP - 110/70 mmHg

PR- 70 bpm

Temp - 98.6°F

SPO2 - 100% on RA

CVS - S1,S2 Heard

R/S - BAE +

P/A - Soft, Non tender.