37 yr old female with fever since 1 month and Shortness of breath since 3 days

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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

M.Abhignya

Roll.No. 83

37 year old female farmer by occupation  came to OPD with complains of & Breathing difficulty 3 days.

HOPI:

Patient was apparently asymptomatic one month ago then she had Fever Low-grade , Insidious onset, Intermittent ,not associated with chills and Rigor aggreviated at Nights ,Relieved with Medications

associated with Generalised Myalgia and Giddiness.

 Clo Burning Micturition

SOB Grade-II Dyspnea on Exertion 

C/O Headache, dragging type radiating to Neck and Hands

 C/O Painful defecation.

Clo Tingling sensation in both Lower limbs

 Nocturia present

No C/O Polyuria ,polydypsia,polyphagia

 No C/O cough; cold; chest pain

No c/o Sweating; Palpitations; orthopnea,PND

No c/o loose stools, Nausea; Vomitings

No C/O loss of appetite, weight loss, Insomnia 

C/o weight gain since 3 months.

Past history:

*K/c/o  of DM-II since 3 years

Started on Tab GLIMI  1 MG & metformin 500 mg PO/OD since  5 month

*Not a K/C/0 HTN,TB,ASTHMA,CAD, EPILEPSY

*Underwent LSCS 18 yrs ago

Toddy drinker, last binge 2-3 days ago

No significant family history

ON Examination Patient is

 conscious,Coherent & Cooperative 

BP: 110/70mmHg

PR:76 bpm

RR:18cpm

Sp02:98% at RA

GRBS:220mg/dl

Temp:98.6F

No pallor,icterus, cyanosis, clubbing,lymphedenopathy,pedal edema

CVS: S1 S2 present,no murmurs 

RIS: BAE present,NVBS

PIA:Soft ,NT

CNS :NFND

Investigations 

USG Abdomen 

2D echo

ECG

CXR

Diagnosis:

PYREXIA secondary to ?UTI

Treatment:

1. Plenty of oral fluids

2.Tab.DOLO 650mg PO TID

3.Tab.GLIMI M1 PO OD

4.Tab.MVT PO OD

5.GRBS Monitoring