A 65 year old male came to casualty with complaints of Fever and weakness of limbs.
July 30 , 2023
Aug 01, 2023
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I have 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 upon with diagnosis and treatment plan.
This is a case of 65 years male came to casualty with complaints of fever and weakness of limbs since 2 months.
Md.Ishad
Roll no: 73
CHIEF COMPLAINTS :
-Fever since 2 months.
-Hiccups since 1 month
-weakness of limbs since 2months.
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 2 months ago then he developed weakness of limbs.
- fever with chills which is intermittent in nature.
- Blood in urine since 1 month
- Burning micturition since 1 month
- Micturition also associated with pain , itching , foul smell since 1 month
- shortness of breath since 1 month
- No appetite since 1 month
- Hiccups since 1month
PAST HISTORY :
K/C/O Type 2 DM since 1 week
Not a K/C/O HTN, Epilepsy, TB, Asthma, CVA, CAD.
PERSONAL HISTORY :
- Mixed diet
- No Appetite
- inadequate sleep
- irregular Bowel and bladder movements
- history of Consumption of alcohol , 2 quarters per day .
FAMILY HISTORY:
- No significant family history
GENERAL EXAMINATION:
Prior consent was taken and patient was examined in a well lit room.
Patient was conscious , coherent, cooperative.Well oriented to time,place and person.
- Pallor present
- No icterus
- No clubbing
- No cyanosis
- No generalised lymphadenopathy
- No bipedal edema.
VITALS :
Temperature : 102° F
Bp - 120/70 mmHg
PR - 82 bpm
RR - 16cpm
spo2 - 100% on RA
SYSTEMIC EXAMINATION :
RS : Bilateral symmetrical chest movement and air entry.
CVS : S1 , S2 heard
No murmurs
PA : soft , no tenderness and distension
CNS : Hmf + intact
sensory and motor system normal
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS :
? AKI , Type 2 DM.