35 year old female with fever and cough

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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. 

Patient came with complaints of fever since 2 months , cough since 20 days 

HOPI -

Patient was apparently asymptomatic 2 months back then she had fever which is high grade , intermittent , associated with chills and rigor , relieved on taking medication 

H/O cough since 20 days which is productive , greenish on color , non blood tinged 

H/O loss of appetite present 

H/O weight loss 15kgs in last 4 months 

H/O SOB , grade II NYHA 

No orthopnea , PND , chest pain , palpitations 

No vomitings , loose stools 

Past history : 

N/k/c/o DM, HTN , TB, epilepsy , CVA , CAD , asthma 

Treatment history:

Hysterectomy done 15 years back 

Personal history :

Mixed diet 

Appetite is decreased 

Bowel and bladder movements - regular 

Addictions - takes alcohol occasionally 

General examination:

Patient is conscious,  coherent , cooperative 

Pallor present 

No signs of icterus , clubbing,  cyanosis , lymphadenopathy , edema 

Vitals:

Temp - 102 F

PR -72 bpm 

BP - 100/70 mmhg 

Rr - 22cpm

Spo2 - 98% at RA

CVS -

S1, S2 present , no murmers 

RS- BLAE + , NVBS heard

P/A - soft , non tender , no organomegaly

CNS - no FND 

 

INVESTIGATIONS -

CUE -

colour - pale yellow 

Appearance - clear 

Albumin - nil

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells -  2 to 3 

Epithelial cells - 2to 3

Rbc - nil

Casts - nil 

Blood urea - 20mg/dl

Se .creatinine - 0.9 mg/dl

Sodium- 138meq/L

Potassium - 3.9 meq /L

Chloride - 101 meq/L

Calcium ionized- 1.04mmol/L

HbsAg - negative 

Anti HCV - non reactive

Hiv - positive 

LFT -

TB - 0.56 mg/dl

DB- 0.14 mg/dl

AST- 15 IU/L

ALT - 11 IU /L

TP - 6.4 gm/dl

ALP - 129 IU/L

Albumin - 2.99 gm/dl

A/G : 0.88

Widal test - negative 

Culture and sensitivity-

Gram stain- 10-15 epithelial cells , 4-5 pus cells seen , moderate gram positive cocci  , few gram negative bacteria 

ZN stain- no acid fast bacilli seen 

Sputum for CBNAAT - positive 

DIAGNOSIS :

VIRAL PYREXIA

DENOVO RETRO VIRAL DISEASE

PULMONARY TUBERCULOSIS 

Treatment -

1. IVF NS, RL @75ml/hr with 1 Amp OPTINEURON

2.INJ.NEOMOL 1gm IV/SOS IF TEMP > 101F

3. Tab.PCM 650mg PO/QID 

4. tab. AUGMENTIN 625mg PO/BD 

5. Tab.MONTEC IC PO/HS

6.Tab. PAN 40mg PO/OD

7. syp.GRILINCTUS 10ml PO/TID

8. Syp.ARYSTOZYME 10ml PO/BD