16 year old female with fever and SOB

- March 29, 2022

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16 year old female Patient who was born out of a second degree consanguineous marriage, no NICU admissions after birth,achieved all the milestones normally.

She attained menarche at the age of 14 years

Bleeds for 5 days for every 30days duration of cycle

She is studying 10th standard

Her daily routine( before )-

She used to getup in the morning by 6 ' clock, get ready for the school, before going to school she takes

Tea biscuits in the morning as breakfast and in the afternoon, she gets lunch from the school management rice and dal & also egg thrice a week and in the evng she doesn't eat anything and she takes her dinner by 8PM rice with curry and goes to sleep by 8 30pm

She came with the complaints of fever since 10 days ,

SOB since one week,

vomiting since 2 days

constipation ( did not pass stools ) since 4-5 days

Patient was apparently asymptomatic 3 months ago then she took covid vaccine in January 2022 following which she had fever high grade, continuous , which lasted for 2 to 3 days , associated with giddiness , easy fatiguability.

Patient was fine till 10 days back then she had complaints of fever, high grade, associated with chills lasted for one week and it was subsided with medication .

no h/o loose stools, vomiting , burning micturition ,cough , cold, sore throat.

C/o of SOB progressed from Grade 2 to grade 3 over last 10 days

Palpitations +

No h/o chest pain , orthopnea, pnd

C/o vomitings , non bilious, non projectile with food as content.

H/O constipation since 4-5 days ( previously bowel habits were regular )

No complaints of pain abdomen .

H/O weight loss = 10 kgs in 2 years

( 2020) : 45 kgs

July 2021 : 40 kgs

now 34kgs

REPORTS : (24/3/22)

HB : 2.4

TLC : 2400

PLT : 24000 (1.5lakh to 4.5 lakh) decreased

RBC : 1.0 million

Mcv : 106 (80-100fl)

MCHC : 50

Pcv : 09(35-45) decreased

Past history

N/k/c/o of DM, HTN, EPILEPSY, TB, ASTHMA, THYROID DISORDERS

PERSONAL HISTORY :

DIET : mixed diet

APPETITE : decreased

BOWEL & BLADDER : constipation ( did not pass stools ) since 4-5 days

Bladder habits were regular.

SLEEP : adequate

No known addictions

FAMILY HISTORY

No history of DM, HTN,asthma,epilepsy, TB, CVDs

GENERAL EXAMINATION :

Ht : 145cm

Wt : 34 kgs

BMI : 16.2 Kg/m2 (N-16.8-17.2)

Pallor +

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

Temp : 98.6f

PR: 136 bpm

Bp : 100/40 mmhg

RR : 18cpm

Spo2 : 98% @RA

jvp raised apex beat - 5th ICS 11/2 inch lateral to midclavicular line s1s2heard , systolic murmur + at pulmonary area, tricuspid area with carotid radiation

Respiratory system - BAE+, NVBS

Abdomen - mild hepatomegaly

CNS - no focal neurologic deficit