20 year old female with facial puffiness and fever since 10 days

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SRI CHANDANA 

Roll no: 98

8th semester  

CASE PRESENTATION 

A 20 year old female labourer came with complaints of fever since 20 days facial and legs swelling since 20 days 

complaints of throught pain SOB difficulty in swallowing  since 3 days 

HISTORY OF PRESENT ILLNESS 

patient was apparently symptomatic 20 days back then developed fever which was insidious in onset gradually progressive high grade with chills and riger not relieving with medication facial puffiness on and off,  legs swelling up to ankle associated with numbness, sob since 3 days Grade 2 MMRC relieved on rest not associated with chest pain , dyspecia since 3 days for both solids and liquids history of headache neck pain which is continuous not associated with vomitings history of facial puffiness one month back subsided by treatment given by local practitioner . Patient has ulcer over the back which is painful . no history of pain abdomen no burning maturation no difficulty in passing stool

History of loss of appittite 

She is not a known case of diabetes hypertension asthma epilepsy thyroid disorders

PERSONAL HISTORY 

As a mother of 3 children this patient wakes up at 5 am in the morning doing her daily chores in her house and sends her older 2 daughters to school and her husband to work she will do remaining chores and she will also goes to work as a daily or weekly labourer and comes home at 5pm to 8 pm based on work she had that day 

Doing all these she neglected her food intake 

Most of the time she skips her break fast and dinner some times she is eating rice with pickle some times 

She want to make sure that her daughters study well so she is working all the time 

She married at the age of 15 yes and had her first child with in a year and in 1½ year she had another daughter and now she is having a 26 months baby 

She didnt gave  milk to all her child because  she didn't produce milk 

Since past few days she is having fever so that she didnt went to work stayed at home but she is doing her chores from past 4 days she is resting and did some of the chores only 

GENERAL PHYSICAL EXAMINATION

Patient is conscious coherent co operative moderately built and nourished 

Pallor present 

No icterus cyanosis clubbing pedal edema 

Lymphadenopathy of bilateral lymph nodes are enlarged 

She is having an abscess 1 to 2 weeks Back which was small in size initially and increased to 3 to 4 cms  and after that her father applied some leaves on that then it opened and pus has came out of that 

Systemic examination 

CVS : S1 S2 + no murmors 

RS : BAE + , NVBS 

CNS :  no focal neurological deficits 

P/A : soft non tender , no organomegaly

Oral cavity  : Norma

Oropharynx : b/l anterior pillar congestion present 

Right side tonsil grade I and left side tonsil grade II tonsilar hypertrophy present 

Posterior pharyngeal wall : granular congestion present 

PROVISIONAL DIAGNOSIS 

Anemia 

with tonsilalr hypertrophy .