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 .
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