17 YRS OLD FEMALE WITH FEVER, SOB AND ANEMIA UNDER EVALUATION

SNEHA CHAUHAN

ROLL NO- 126

2017 BATCH

9th SEMESTER

PREFINALS PRACTICAL CASE BLOG

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A 17 year old female who is a 10th standard student came to the current hospital for blood transfusion hence was admitted on the 23rd March 2022, along with chief complaints of

Shortness of breath since 1 month- which increased severely since the past week
Fever since 4 days
Constipation since 3 days and
2-3 episodes of vomitting since 2 days from the Date of admission.

History of presenting illness-

Patient was apparently asymptomatic one month back, then she developed

Shortness of Breath

sudden In onset
Gradual in progression
She would walk slower than her peers often stopping to catch her breath (Grade 2 SOB according to MMRC scale)
This would hamper her from going out as much or even doing any intensive work, work that required her to move about a lot, etc.
One week from the DOA, the SOB increased from Grade 2 to Grade 3 SOB where she would get breathless only after walking a few metres.
It wasn’t associated with any postural changes, no diurnal variation, cough and chest pain.

2. Fever

sudden in onset (occurred one night)
Gradually progressing
Since 4 days from DOA
which was high grade
Relieved on taking medication

3. Constipation

since 3 days,
Relieved on giving treatment
Not associated with abdominal pain or bleeding

4. Vomitting

had 2-3 episodes
Non projectile,
Food was majority of the content
Not associated with blood

She had gone to another hospital to get herself evaluated from which she was diagnosed to have anemia.

From there she was referred here to the current hospital for blood transfusion, Where her complaints were also treated.

Past history-

no similar complaints in the past
No history of hypertension, diabetes, tuberculosis, asthma, epilepsy or any thyroid disorders

Personal History-

DIET-

She would often just drink tea and have some biscuits before going to school.
For her lunch- the school often provided lunches for their students often times it being rice with dal or spinach curry.
There usually isn’t any snacks involved in her diet during the evenings
Dinner- patient usually eats rice with curry (usually vegetarian ie lady fingers etc)

She consumes chicken but not so very often,
Does not consume adequate yoghurt or milk in her diet.

appetite- was lost a few days ago but is normal as of now
Bowel and bladder- regular currently (29/03/2022)
Sleep is adequate
No addictions as such

Menstrual History-

she attained menarche at the age of 14y
Usually there’s normal flow, with 3 to at most 5 days of continuous bleeding
Changes pads 3 times a day
Usually associated with back pain and mild cramps
No clots
As of recently she hasn’t attained her regular usual cycle this month, which normally occurs at around the second week of every month.

Family history- insignificant

General Physical Examination-

Thinly built and moderately nourished

Vitals

pulse rate: 136bpm
Temperate: currently afebrile
Respiratory rate: 18cpm
Blood pressure: 100/40 mmHg

Pallor present

On 24/3/2022 (reference- Intern’s blog https://ramyatha154.blogspot.com/2022/03/16yrf-with-pancytopenia-fever-under_24.html for photos taken on 24th March 2022).

On 29/3/2022

No signs of icterus, cyanosis, lymphadenopathy or clubbing.

Cardiovascular system examination-

Inspection- raised JVP seen

Palpation- Parasternal heave present
Percussion- apex beat felt at left 5th intercostal space, about 4 cm lateral from mid clavicular line
Auscultation- systolic murmur heard over pulmonary and tricuspid area.

Respiratory examination-

Inspection of chest-