CLINICAL CASE REPORT

MEDICINE BLOCK

NAME
MATRIX NO.

: NORISAH BINTI ABU

: 113891

YEAR

:4

GROUP

:7

ACADEMIC SESSION

: 2014/2015

HISTORY TAKING:

Patients Identification:
Name
: Rashida Khaleel Ahmed Bepari
Age
: 41 years old
Race
: Indian
Sex
: Female
Occupation
: Housewife
Address
: Kasai Galli, Belgaum
Date of admission
: 24/10/2014
Date of clerking
: 27/10/2014
Informer
: brother
Chief Complaint
My patient complained of having cough for 20 days.
History of Presenting Illness (HOPI) :
Patient was apparently alright 20 days back when she developed cough
which is insidious in onset and progressive in nature. It is associated with
minimal expectoration and was yellowish in colour. It is increased during
night and relieves on taking medications.
Patient also complained of having fever for 10days back which was
continuous type but increase in the evening. It also relieves by taking
medication.
My patient also complained of generalized weakness and headache for past
10days. Generalized weakness present on exertion which relieves at rest.
Headache was insidious in onset and progressive in nature.
Patient also complained about nausea and vomiting for past 4 days. Vomiting
was about 4 5 episodes. Vomitus includes food particles. It was relieves by
taking medication.
Systemic Review:
Cardiovascular System:
No chest pain
No ankle swelling
No palpitation
S1 and S2 heard, no murmur
Respiratory System :

coughing associated with yellowish sputum production

No haemoptysis
No wheezing

Genitourinary System:

No pain during mictrition

No back pain

No delay in passing urine

Gastrointestinal system:
Nausea and vomiting
No loss of appetite
No abdominal pain
No dysphagia
Endocrine System:

no swelling in the neck

Musculoskeletal System:

No muscular pain

No join swelling

No cramp
Central Nervous System:

No blurring vision

No headaches

No loss of consciousness
Haematological System :

no bleeding tendency

no bruising
Past Medical and Surgical History:
She does not have hypertension, diabetes mellitus, tuberculosis, or asthma.
Family History:
There was no similar symptoms in her family and all of them had no medical
illness or any chronic disease such as Diabetes Mellitus, heart disease and
asthma.
Personal and social history:
There is no significant history regarding this. She is a non vegetarian. Her
sleep was normal. Her bladder activity also normal. She had reduced
appetite thus reduced in bowel movement.

Drug History:
She admitted that she had consumed pain killer over the counter to relieve
her pain. There is no history of allergic to drugs.
SUMMARY:
My patient, Rashida Khaleel, 41 years old, from Belgaum, was admitted due
to chronic cough for 20 days associated with yellow expectoration. She also
complained of having continuous fever for 10days which was rise in the
evening. She also has generalized weakness which was relieved at rest for
10days and also having vomiting after meal for 4days. The content was food
particles. There was no hemoptysis, no abdominal pain, no muscular pain,
and no joint swelling.
PHYSICAL EXAMINATION:
General Examination:
Inspection:

The patient was lying in supine position.

She was alert and conscious, orientated to time, place and person.

She was not in pain.

- She had labored respiratory.

However , she look pale and lethargy.

Her hydrational status and nutritional status are not clinically adequate
because loss of skin
turgor.

There was no sign of gross deformity and no abnormal involuntary

movement.

There was no skin discoloration.

There was an intravenous cannula attached to the patients left

forearm.
Vital

Signs:
Temperature
Blood Pressure
Respiratory Rate
Pulse Rate
Rhythm
Volume

: 98.6 degree F
: 100/80 mmHg
: 20 breaths per minute
: 96 beats per minute
: regular
: good

Upper limb :
Hand:

Palmar surface was warm and dry.

Palmar crease was pink in color.

Finger & nails

No clubbing.

No peripheral cyanosis


No koilonychias.

No leukonychias.

Capillary filling was good

Forearm

No scratch mark

No bruises

No rash

No flapping tremor.
Head:
Eyes:

The patients conjunctivae were pale.

There was no yellow discoloration of the sclera.

Ear,

Nose and Mouth:

There was no discharge from the ears or nose.
Good oral hygiene
Her mouth and tongue was moist.
Her tongue was not coated.
No central cyanosis.
No bleeding of the gums.
No glossitis , no angular stomatitis.
No fetor hepaticus.

Chest wall and axillae.

No spider naevi
Lower limbs:
No ankle edema.
Specific Examination
A) RESPIRATORY SYSTEM
Inspection:
-no surgical scar
-no deformities of the chest
-symmetrical movement of the chest wall
-accessory muscle is used to breath
-no skin decolourisation
Palpation:
-no apex beat shift
-normal chest expansion
-normal tactile fremitus

Percussion:
-resonance percussion at the both sides
-normal tactile vocal fremitus
Auscultation:
- Normal vesicular breath sound heard
Summary :
Mrs Khaleel, a 41 years old lady, was being examined to have anaemia and
normal respiratory system functions.
B) PER ABDOMINAL EXAMINATION
Inspection:
-flat abdomen
-Abdomen move with each respiration
-Inverted umbilicus
-No surgical scar, visible pulsation, dilated vein, skin discoloration, visible
peristalsis
Palpation:
a) Light palpation
- Abdomen was soft and no guarding
b) Deep palpation and percussion
-No tenderness
-No hepatomegaly
-No spleenomegaly
-Kidney was not ballotable
-No shifting dullness
Auscultation:
-Normal bowel sound
-No renal bruits
Summary:
Mrs Khaleel, a 41 years old lady, was being examined to have normal
abdomen with no organomegaly or ascites.
A. Problem List :
I. Symptoms:
- Cough with expectorant
- Fever
- Generalised weakness
- Vomiting

II. Signs :
-

Tachypnea
accessory muscle is used to breath

III. Provisional Diagnosis:

- Viral fever
IV. Differential Diagnosis:
- Pulmonary Tuberculosis
- Viral pharyngitis
- Gastroenteritis
B. Relevant Investigation
1. Full blood count
a. Normal blood picture
2. Chest Radiograph (PA view)
a. Cardiac is normal in size
3. Microbiology
a. HCV ELISA
b. VDRL

: non-reactive
: non reactive

4. Biochemical markers :
normal
a. Urea
: 45 mg/dl
(15-45 mg/dl)
b. Creatinine : 1.9 mg/dl
(0.5 1.5 mg/dl)
c. Uric acid
: 3.4 mg/dl
( 3.5 7.2 mg/dl)
5. Liver function test
a. Total Bilirubin
: 0.7 mg/dl
b. Direct bilirubin
: 0.2 mg/dl
c. Total protein
: 6.3 gm/dl
d. Serum albumin : 3.4 gm/dl
e. A. G. ratio
: 1.1
f. SGOT (AST)
: 21 IU/L
g. SGPT (ALT)
: 19 IU/L
6. Urine Routine and Microscopy
a. Colour
pale yellow

(0.2 - 1.0) mg/dl

(0.0 - 0.3) mg/dl
(6.0 - 8.5) gm/dl
(3.2 - 5.5) gm/dl
(1.0 - 2.0)
(15 - 37) IU/L
(30 - 65) IU/L

b.
c.
d.
e.
f.
g.
h.
i.
j.

Appearance
Reaction
Albumin
Sugar
WBC
RBC
Epithelial cell
Casts
Crystals
-

clear
acidic
absent
absent
nil
1-2
nil
nil
nil

Final Diagnosis
Viral fever
C. Principle of Management :
1. Medical care :
- IV fluids normal saline with MVI @75ml/hour
- Injection xone 1gm 1 0 1
- Tablet paracetamol 500mg 1 0 1
- Injection rantac 50mg 1 0 1
- Injection emset 4mg 1 1 1
- Tablet doxy 100mg 1 0 1
2. Monitoring the general medical condition.
- Strict vital signs charting
- Strict temperature charting.
DISCUSSIONS :
Illnesses caused by viruses are among the most frequent causes of
fever in adults. Symptoms can include a runny nose, sore throat, cough,
hoarseness, and muscle aches. Viruses also may cause diarrhea, vomiting, or
an upset stomach. My patient presented with typical presentation for viral
fever.
Treatment of viral fever is purely symptomatic with antipyretic and
analgesic drugs. Bed rest and adequate fluid intake is advised. Nasal
decongestants may be beneficial. Specific antiviral therapy is not routinely
recommended. Steroids are not advised as it may lead to bacterial superinfection. Only in cases of super-infection do antibiotics need to be

prescribed. It is important that antibiotics are NOT routinely used for

prophylaxis.
Complications of viral infections like pneumonia (viral or superinfection by bacteria) need to be addressed specifically by clearance of
respiratory secretions and utilising ventilator assistance if hypoxia is severe.
Symptoms of gastroenteritis should be managed with anti-motility agents.
Most viral fevers recover completely in a week although fatigue may persist
for a few weeks.