PYREXIA OF UNKOWN ORIGIN

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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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

43YR OLD FEMALE WITH CHIEF COMPLAINTS OF FEVER SINCE 8 MONTHS

CHIEF COMLAINTS OF SOB SINCE 5 MONTHS

HOPI

-PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN SHE DEVELOPED FEVER OF HIGH GRADE,CONTINOUS TYPE,NO DDIURNAL VARIATION,RELIEVES ON TAKING MEDICATION IN 2-3 DAYS,THEN FEVER SPIKES AFTER 6-7 DAYS NOT A/W HEADACHE.

NO H/O COLD,COUGH.

NO H/O PAIN ABDOMEN,DIARRHOEA,CONSTIPATION,BURNING MICTURITION.SPB INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE FROM GRADE1 TO GRADE 4,H/O CHEST PAIN9BURNING TYPE0,ORTHOPNEA PRSENT,OND-NEGATIVE,NO H/O PEDAL EDEMA,ABDOMINAL DISTENSION.

H/O REGURTITATION,H/O LOSS OF APPETITE,H/O GENERALIZED BODY PAINS,OLIGOMENNORHIA.

PAST HISTORY- N/K/C/O HTN,DM,EPILEPSY,THYROID DISORDERS,CAD,CVA,TB

GENREAL EXAMINATION:

PT IS CCC

NO SIGNS OF PALLOR,CYANOSIS,CLUBBING,LYMPHADENOPATHY

PR 76 BPM

BP 100/70 MMHG

SPO2 99

GRBS 108

RR 38 CPM

PERSONAL HISTORY

LOSS OF APPETITE PRESET

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD

RS BAE+

GIT NT SOFT

CNS  NFND PRESENT

INVESTIGATION:

RFT   14-12-2023 07:29:PM   UREA 19 mg/dl 42-12 mg/dl  CREATININE 0.8 mg/dl 1.1-0.6 mg/dl  URIC ACID 2.0 mg/dl 6-2.6 mg/dl  CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 4.3 mg/dl 4.5-2.5 mg/dl  SODIUM 138 mEq/L 145-136 mEq/L  POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L  CHLORIDE 103 mEq/L 98-107 mEq/L	LIVER FUNCTION TEST (LFT)   14-12-2023 07:29:PM   Total Bilurubin 0.65 mg/dl 1-0 mg/dl  Direct Bilurubin 0.17 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 30 IU/L 31-0 IU/L  SGPT(ALT) 33 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 143 IU/L 98-42 IU/L  TOTAL PROTEINS 7.8 gm/dl 8.3-6.4 gm/dl  ALBUMIN 4.12 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.12
HBsAg-RAPID   14-12-2023 07:29:PM Negative	Anti HCV Antibodies - RAPID   14-12-2023 07:29:PM Non Reactive
WIDAL TEST   14-12-2023 07:29:PM   S.typhi "O" Antibodies No Agglutination seen    S.typhi "H" Antibodies No Agglutination seen    S.PARATYPHI "AH" ANTIBODY No Agglutination seen    S.PARATYPHI "BH" ANTIBODY No Agglutination seen	COMPLETE URINE EXAMINATION (CUE)   14-12-2023 07:29:PM   COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN Nil    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 2-4    EPITHELIAL CELLS 2-3    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil

DIAGNOSIS:

PYREXIA OF UNKOWN ORIGIN

TREATMENT:

IV FLUIDS DNS @75 ML/HR

TAB.NAXDOM 250MG PO/BD

TAB DOLO 650 MG PO/BD

TAB.SHELCAL CT 500 MG PO/OD

TAB PAN 40 MG PO/OD

TAB.NEUROBON FORTE PO/OD

NEB BUDECORT 6TH HRLY

TAB.FLEXON MR PO/BD

ADVICE AT DISCHARGE:

TAB.NAXDOM 250MG PO/BD

TAB DOLO 650 MG PO/SOS

TAB.SHELCAL CT 500 MG PO/OD

TAB PAN 40 MG PO/OD

TAB.NEUROBON FORTE PO/OD

TAB.FLEXON MR PO/BD