16 year old female with fever

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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 diagnosis and treatment plan.  

A 16 year old female student, resident of dameracherla presented with the chief complaints of 

1. Fever since 7 days.  
2. Dizziness since 2 days. 
3. Cough since 1 day 

History of presenting illness: 

The patient was apparently asymptotic 7 days back when she had fever. The fever was of high grade, intermittent in nature and was reduced on taking medication(paracetamol ). It was not associated with chills or rigor. On the third day of fever she was taken to the local doctor where tests were done and was told to be typhoid positive. 

She was give injections (unknown) and salines everyday for 3 days. 

As the fever was not decreasing (day6) she was taken to a hospital in dachapally when CBP was done and the patient was told that there was a decrease in blood cells. 

On day 7 of illness, she went to a hospital in Miryalaguda where on checking BP she was told that it was less. 

From there she was shifted to our hospital. 

Since day 2 of hospitalisation, she did not have any episodes of fever. 

Past history: 

-H/o RTA 3 Years ago after which he got implant in right tibia.

-H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound. 

-patient was diagnosed to be sputum + TB and was started on ATT 

Patient complains of dizziness on getting up since 4 days. She takes the help of the attender to go to the washroom as she feels that she might fall down. 

She also complains of cough without sputum since 2 days. It showed nocturnal variation. 

She also complains of swelling of the lower limbs since two days and swelling of the right hand since 1 day. 

Personal history 

 Appetite: normal 

 diet: mixed

Bowel and bladder : regular 

Sleep: adequate 

Allergies: none 

GENERAL EXAMINATION:

The  patient is conscious, coherent, cooperative.

Pallor was seen. Edema  was seen on both the lower limbs till thigh. Right upper limb showed edema. 

No signs of  icterus, cyanosis, clubbing, lymphadenopathy. 

Vitals:

Temp-98.4 degrees F

BP-120/78 mm hg

PR-68bpm

RR-16cpm

Respiratory system examination: 

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 

CVS: 

S1 and S2 are heard. 

No abnormal heart sounds were heard 

CNS:

No fuctional deficits were noticed. 

Per abdominal examination: 

Abdomen was soft and tender. 

No organomegaly was noticed.