80YEARS OLD MALE WITH C/O FEVER

80YEARS OLD MALE WITH C/O FEVER SINCE 1DAY

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I've 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 a diagnosis and treatment plan. 

Chief complaints :

Patient came with chief complaints of fever since 1 day

HOPI

Patient was apparently asymptomatic 1 day back then he developed fever high grade a/w generalised weakness 

Patient was unable to get up from bed since morning 

H/o involuntary passage of stools and urine since today morning 

No h/o neck stiffness,neck pain 

No h/o cold cough 

No h/o burning micturition 

No h/o headache vomitings

Past history:

H/o altered sensorium 3 years back and got admitted in kims Narketpalle 

K/c/o CKD since 15 years 

K/c/o Dm since 20years on tab glimiperide 1mg + metformin 500mg

H/o umblical hernioplasty surgery 

H/o CVA 4 years back

Not a k/c/o HTN Tb asthma 

FAMILY HISTORY:

No similar complaints in family 

Personal history:

Occupation:farmer 

Appetite: normal

Diet: mixed

Addictions: Alcohol occasionally 180ml

Sleep: adequate

General examination:

Pt is conscious coherent cooperative 

Mild Pitting type Oedema in left lower limb

No signs of palllor ,clubbing, cyanosis, pallor ,icterus, lymphendenopathy 

Vitals :

Bp :150/90mm hg

PR:102bpm 

Temp: 102F

RR:28cpm 

Grbs:227 mg%

Per Abdomen:

Shape of abdomen-distended

Umbilicus -everted

Abdomen moves accordingly with respiration.

 No sinuses

 Scars present at right epigastric and umblical region (past surgery of umblical hernia)

Abdomen is soft, no tendernes

No free fluid

Hernial orifices-Normal

No organomegaly

Bowel sounds- present 

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central 

Tactile vocal

Fremitus                   Right                              Left

Supraclavicular          N                                   N

Infraclavicular           N                                   N

Mammary                   N                                  N

Inframammary          N                                  N  

Axillary                        N                               N

Infraaxillary               N                                N

Suprascapular           N                                N

Infrascapular            N                                N

-Percussion                Right                      left

Supraclavicular          R                                R

Infraclavicular           R                                R

Mammary                   R                               R

Inframammary          R                               R

Axillary                        R                             R

Infraaxillary               R                             R

Suprascapular           R                              R

Infrascapular             R                             R

R-Resonant

-Auscultation            Right                                       Left 

Supraclavicular        NVBS                                    NVBS

Infraclavicular         NVBS                                   NVBS

 NVBS

Infraaxillary             NVBS                                 NVBS

Suprascapular         NVBS                                  NVBS

Infrascapular          NVBS                                  CREPTS +

Central Nervous system:

 GCS :E4V5M6

Conscious

Cranial nervers -normal

Tone                 Rt                  Lf 

UL                     N                   N

LL                      N                   N

Power               Rt                  Lf

UL                    5/5                 5/5

LL                     5/5                 5/5

Fine touch       Rt                  Lf 

UL                     N                   N

LL                      N                   N

Reflexes.          Rt.                 Lt

Biceps               ++                 ++

Triceps             ++                  ++

Supinator        ++                  ++

Knee                 ++                  ++

Ankle                ++                  ++

Provisional diagnosis: pyrexia ?

Investigations:

Date 28/10/23

TREATMENT :

1.IV FLUIDS NS RL@50ML/HR

2.INJ CEFTRIAXONE 2GM IV/BD

3.INJ OPTINEURON 1 AMPULE IN 100ML NS IV/OD

4.INJ PAN 40 MG IV/OD

5.INJ HAI S/C PREMEAL TID

6.INJ NEOMOL 1GM IV/SOS

7.TAB SHELCAL PO/OD