31YR OLD FEMALE WITH RECURRENT PUO
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Name : Supriya .K ( Intern )
Roll Number : 63
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.
31YR OLD FEMALE ,Resident of Sajjan Puram came to OPD with chief complaints of
fever ,associated with Chills ,Rigors ,Head ache ,Joint pains and generalised weakness since 2 months
patient was apparently asymptomatic 2 months ago , then developed fever associated with chills ,rigors ,head ache ,joint pains and generalised weakness ,went to local hospital , (on investigations , WIDAL positive , ESR raised (26mm ) ,CRP -6.01 ,K+ 2.9 , Na+ 133 , ON USG ,Cystitis and Grade 1 fatty liver found
diagnosed as Typhoid fever and given medications ( unknown ).
her symptoms were not relieved on taking medication. So, she came to our hospital for further management .
burning micturition present
No H/O nausea ,vomiting ,loose stools
No H/O cough ,cold
Past History :
Not a known case Of DM ,HTN ,asthma ,epilepsy ,TB ,thyroid
SEQUENCE OF EVENTS :
In 2019 -(i.e .., 3yrs ago ) She developed fever ,which was sudden in onset ,low grade , intermittent type , lasted for 2 months duration , which was diagnosed as typhoid fever, relieved on taking medication .
but fever recurrs every 8 months ,since then .
In 2020 ,( i.e 2yrs ago ), she developed headache ,which was sudden in onset , lasted for 1hr duration , in the parietal region radiating to neck ,increased in intensity on exposure to loud sounds (phonophobia) , went to the hospital at Miryalaguda ,took medication for 20days ,and headache got relieved for few months .
then ,associated with fever ,which reccurs every 8 months .
In October 2022,(i.e ..,2months ago ) She developed joint pains ,which involves large joints and Spine .( small joints not involved ) . Intensity increases during night time, and lasts till 1 hour after wake up in the morning ,and relieves on performing daily chores , associated with fever.
Personal History:
Appetite - reduced
Diet - mixed
Sleep -adequate
Bowel and bladder movements - regular
Addictions - No addictions
Allergies - No allergies
GENERAL EXAMINATION:
Patient is conscious ,coherent and cooperative
Temp- 98.4F
Bp- 110/70 mmHg
PR- 74bpm
RR- 20cpm
No pallor ,Icterus ,Cyanosis , Lymphadenopathy,Edema
Visceral fat and Bilateral arm Muscle Mass :
Systemic examination:
CVS -S1, S2 Heard ,No murmurs
RS- BAE+
CNS- HMF intact
P/A - soft, non tender
Provisional Diagnosis :
PYREXIA under Evaluation
Investigations:
Serology :
HIV - Negative
HBsAg - Negative
HCV - Negative
Mantoux test : Negative
2D ECHO :
Trivial TR+/MR+/ AR+
No RWMA ,No MS/AS ,No sclerotic AV
Good LV systolic function
No diastolic dysfunction, No PAH /PE
EF: 50
Management:
TAB PAN 40MG PO/OD
TAB DOLO 650MG PO/TID
INJ NEOMOL 1GM IV (IF TEMP> 101F)
TAB ULTRACET 1/2 TAB PO /QID
SOAP Notes :
Ward
Day - 2
S
Body pains subsided
Head ache subsided
No fever spikes
O
Patient is conscious coherent and cooperative
Temp- 98.4F
Bp- 110/70 mmHg
PR- 74bpm
RR- 20cpm
Cvs-S1 S2+
Rs- BAE+
CNS- HMF intact
P/a- soft, non tender
A
Pyrexia under evaluation
P
TAB PAN 40MG PO/OD
TAB DOLO 650MG PO/TID
INJ NEOMOL 1GM IV (IF TEMP> 101F)
TAB ULTRACET 1/2 TAB PO QID
CASE DISCUSSION:
I didn completely get the sense of it. Can you explain it Supriya? Like the second time u mentioned it, you haven’t mentioned any episode of fever in 2021
[1/9, 12:52 AM] Moulika Ma'am 2k16: Also, in 2019 the fever was typhoid and it lasted for 2 months and it relived on medication after 2 months? When did she start the medication?
[1/9, 12:54 AM] Dinesh Datta Sir 2k15 : How do we know that typhoid is totally eradicated and they are not carriers,who are prone for relapse?
[1/9, 12:55 AM] Moulika Ma'am 2k16: In 2022, was the fever first or the joint pains? And the large joints meaning what all were involved? And weren’t there chills like the present episode.
Also, do you have any history of the medications used which then relived her symptoms?
And do any of those symptoms associated with the episodes of fevers persist later as well?
[1/9, 12:57 AM] Moulika Ma'am 2k16: And like Avinash already asked, if possible the previous episodes temp graph? Or atleast a vague idea of the temperatures by the Pt or the attenders?
[1/9, 1:01 AM] Moulika Ma'am 2k16: Also, her present fever charting? And her present condition?
[1/9, 1:01 AM] Moulika Ma'am 2k16: Typhoid dilutions? From the previous reports maybe?
[1/9, 1:05 AM] Moulika Ma'am 2k16: Didn’t she get typhoid tested in 2020
[1/9, 1:07 AM] Moulika Ma'am 2k16: Any idea of what extra medication have we given that the previous doctor hasn’t that helped reduce her symptoms after 2 long months?
My Answers to the Above questions:
[1/9, 3:04 PM] Supriya: I thought ,it's unnecessary to mention ,she developed fever in 2019 ,2020 ,2021 ,2022 .
So, I have mentioned ,she developed fever ,which recurrs every 8 months
I have mentioned , the new symptom ,which is specific to that particular year , that wasn't there before .
So , in 2020 , the headache she developed wasn't there in 2019 , as such her joint pains ,which she developed in 2022 wasn't there in 2021 ,2020 ,2019
That head ache ,which she developed in 202O , relieved for few months ,after using Medications for 20days .So, she thought her headache was completely resolved ,but again when she developed fever in that year(2020) ,head ache was associated with it
She developed joint pains, (since October ,2022 )which involved large joints ( elbow ,knee ,shoulder joints and spine )
But not interphalangeal and metacarpal joints .
She developed joints pains in 2022 ,which she wasn't experienced before .
So, her fever which developed 3yrs ago ,followed by joint pains .(acc to it ,her fever is first and joint pains followed it )
[1/9, 3:08 PM] Supriya: In 2021 , there were no new symptoms developed by her ,but suffered with the symptoms which she developed before( i.e fever and head ache )
So in my time line of events ,there is no 2021
but I clearly mentioned ,Fever recurrs every 8 months
[1/9, 3:09 PM] Supriya: and My Provisional Diagnosis and Final diagnosis is not TYPHOID FEVER
[1/9, 3:10 PM] Supriya: Its PYREXIA UNDER EVALUATION
[1/9, 3:13 PM] Supriya: I have mentioned ,she was diagnosed with typhoid fever in just a history ,based on patient experience and previous reports
[1/9, 3:14 PM] Supriya: I have nt explained My pattern of fever is step ladder pattern ( showing insidious onset ,continuous type )
[1/9, 3:15 PM] Supriya: and her culture reports are negative for organisms
[1/9, 3:22 PM] Supriya: These were the reports ,i went through, when she was in our hospital
[1/9, 3:22 PM] Rakesh Biswas Sir Gen Med HOD: Thanks @Supriya for the clarification. Please share the above clarification as well as conversation into the body of your case report at the end under the heading "discussion"
[1/9, 3:23 PM] Supriya: I have mentioned same things in the history
[1/9, 3:23 PM] Supriya: not even extra reading
[1/9, 3:24 PM] Supriya: Her temperature recordings were between ( 97F -100F) during hospital stay
[1/9, 3:24 PM] Supriya: Sure sir
[1/9, 3:25 PM] Rakesh Biswas Sir Gen Med HOD: Good. But it's nice to have a separate discussion section in the case report that highlights the interactions happening as a result of your case report in which also highlights the impact of the case report on your learning ecosystem
[1/9, 3:28 PM] Supriya: This is the evidence for head ache ,for which she went to Miryalaguda hospital
[1/9, 3:29 PM] Rakesh Biswas Sir Gen Med HOD: CT images should always be taken frame by frame, particularly if you want to show a finding.
Not in this manner where there is a risk of patient identifiers becoming visible
[1/9, 3:29 PM] Supriya: I will add it in ,Case report sir
[1/9, 3:29 PM] Supriya: Yess sir
[1/9, 3:30 PM] Supriya: But ,there is no finding sir
[1/9, 3:30 PM] Supriya: I provided as evidence sir ,thats it
[1/9, 3:30 PM] Supriya: So that ,everyone doubts will be clarified
[1/9, 3:32 PM] Rakesh Biswas Sir Gen Med HOD : Yes we call it as inserting supporting evidence for the sequence of events anecdotes in a case report 👍
Dinesh datta sir 2k15 : any rash ?
Supriya : No sir
PSYCHOSOCIAL COMPONENT:
This 31year Old Female patient : who is a agriculture worker by Occupation , came with the above complaints as explained in biological component
In 2019: ( had her first episode of fever ) - Relating to her psychosocial component :
Lost her Brother ,who was big support system to her family (single sibling ) and was soo affectionate with her , In the same 2019 year . Not only this ,Her Husband Extra marrital affair with her Cousin sister was exposed , which affected her in the same 2019 year .
In 2020 : ( had fever along with headache ) -
Relating to her psychosocial component :
Lost her Mother , since she was the Single parent ,who raised her ,as her Father expired during her childhood afffected her deeper ( she cried and became emotional while expressing with me about her mother ) ,She was that connected to her .
Religious Philosophy: She is Hindu by religion , During her Childhood ,her father ,who frequently visited church near by their home place , was Started believing Jesus Christ and they converted to Christianity but her husband family is a Hindu family . (they Married 15Years ago , Consanguineous marriage- He is her Brother in law ) has 2 female child - 13yr and 11yr old .
In the Year 2021 : her husband was On Ayyappa swamy Maala , ( as she is fond of Bible and Prays Jesus ) ,it was very difficult situation to her but she performed rituals in their home ,as she thought people will blame her if she doesn't involve in it . Due to strong belief of doing bad against to Jesus . She fell sick after rituals .
Her Husband Personality in a brief : (accoding to Pt)
He used to work together with her in the Agriculture Farm , they were healthy and also led happy life .3 years ago , he was into extra marrital affair with his wifes cousin sister and it was known by his wife through people and also observed changes in her husband behaviour ,She warned him about it . He gave some vague explaination and stopped it . Then, he continued happy life with his family .
7 months ago , he started New Tea Shop by quitting agricultural work but his wife continued the same agricultural work. They led happy life by sharing their household works and financial burden and income till 2months after his business established
but Suddenly ,She observed changes in his behaviour ,he became soo rude and started scolding her (like ur soo unlucky to me , Neighbous wives are so good ,they will do their work and take care of their husbands so well ) .He avoided her and was totally on Mobile ,Chatting with another lady over nights . She noticed some Messages related to their relation on his Mobile and questioned her husband. Again he gave some vague explaination and scolded her saying you studied only till 5th standard , its better studying nothing or completing higher Education ,this half study made you more foolish person . He didnt even tried to console her after this incident .She thought iam alone ,No one is there for me ( as she doesnt has her Father ,Mother and Brother ) I should only live for my Children .She had soo many thoughts about her children , If something happens to me ,what will be the future of my children .
Sexual relationship was not good since he was into extra marrital affair .
His behaviour affected her more
Then she came with C/O fever , headache, generalised weakness and Joint pain since 2 months .
During Conversation, Patient is comfortable sitting over Chair .Expressed her Inner self without hesitation ( Saying Your like God to Me ,as I expressed my feelings to only to God through Bible , I never Expressed my feelings to anyone till now like Cousins,relatives ,friends , as they try to bully my husband and my life )
Ruling Out other medical illness and through her Normal Investigation findings , I mentioned her Diagnosis as Pyrexia Under Evaluation.
Eye to Eye Contact Present , PMA - Normal
Ruling Out - Dysfunctionality , i dont want to label my Patient with any Psychiatric illness
Saying Mild/moderate / Severe Depression and adjustment issues .
According to me , She Requires Therapy to express her deeper inner self and Marrital Counselling by follow up with 2 more sessions .
IAM RELATING THIS CASE TO PNI
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