Case: Viral Pyrexia with swollen extremities

Neha Pradeep, MBBS 9th semester



Roll no: 99



This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .



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.

Case:
16 year old girl with fever since 12 days and associated dry cough. Has swollen lower and upper limbs bilaterally. 

History of Presenting Illness:
Patient was apparently asymptomatic 12 days ago when she developed fever. It was sudden in onset and intermittent.
It was not associated with chills or rigors. 
She has cough since 4 days. It is non productive. 
She has no associated bleeding manifestations, headache or body pains. No itching or rashes. 

She went to the local hospital after the onset of fever, where they diagnosed her with typhoid. They gave her anti-pyretics and saline, after which there was swelling of her upper and lower limbs bilaterally.  



Past History:

Patient has no similar complaints in the past. 
No history of Diabetes, Tuberculosis. 

Personal History:

Diet: Mixed 
Appetite: Normal
Bowel and Bladder: Regular 
Sleep: Adequate 
Allergies: None 

General Examination: 

Patient is conscious, cooperative and coherent. 
Moderately built and moderately nourished. 

Pallor: Absent 
Icterus: Absent 
Clubbing: Absent 
Cyanosis: Absent 
Lymphadenopathy: Absent 
Edema: Swelling of extremities are present but non pitting. 

Vitals: 
Pulse: 110 beats per minute 
Temperature: Afebrile
Blood Pressure: 110/80 mmHg
Respiratory Rate: 18 cycles per minute 


Lab Reports: 


Hemoglobin: 10 gm/dl
Total count: 18,100 cells/cumm
PCV: 28.9  vol% 
MCV: 75.7 fl
MCH: 26.2 pg
MCHC: 34.6 % 
RDW-CV: 15.1 %

ECG: 


RFT and LFT:


Urea: 15 
Creatinine: 0.6 
Calcium: 9.9
Phosphorus: 2.0
Sodium: 138
Potassium: 3.7 

AST: 78
ALT: 42
ALP: 285 




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