This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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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 up with diagnosis and treatment plan.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
Kota Hrithik Raj
Roll no 76
Case Report
A 80 year old patient came to OPD with chief complaints of fever since 10 days.
History of present illness
Patient was apparently asymptomatic 10 days back then he developed fever that is insidious in onset, high grade, intermittent in nature, associated with chills and rigors, relieved on medication, no evening rise of temperature.
Patient said that there was burning micturation few days back, with increased frequency, has dribbling of urine on straining and postvoidal residue since 5 days. with no change in colour, odour and volume.
With these compliants he went to a local doctor where urine test was done and he was told there were pus cells in the urine.
He was given some injection and normal saline infusion.
After going home he had same complaints of fever which was being relieved only on using medication following which he came to our hospital 5 days back.
The patient had same symptoms of burning micturation, increased frequency, post voidal residue and colour milky white with offensive smell.
The patient added that he has difficulty in swallow solid food when compared to liquid. Dryness in the throat is present and feels that his throat is constricted while swallowing food.
He complaints of generalized weakness since onset of symptoms 10 days back and unable to walk since then and barely sit up with help. According to his attenders he is more lethargic.
He has constipation since 6 days.
He passed stool yesterday night after giving enema.
There are no complaints of headache, nausea and vomiting, body pains, shortness of breath.
Daily routine
He wakes up 5am in the morning gets freshened up and goes to get milk.He then drinks tea at 7am in the morning.Then he does few household chores like boiling water, cleaning the house.
Then at 9am he eats breakfast.
Then he takes rest for sometime and goes to a forest to get sticks and tie them together and make broomsticks.
Then at 2pm he eats his lunch and takes rest for sometime and goes out for a walk and then have dinner at 8pm.
He goes to bed by 9pm.
Past history
The patient said he had surgery 5 years ago because he was not able to pass urine properly. Most likely it was BPH and TURP was done.
History of UTI post surgery is
He was also incidentally diagnosed with diabetes and has been on medication since then.
He was also diagnosed with hypertension and on regular medication since then.
Patient also complaints of bilateral knee joint pain since 5 years - pain increases on walking for long time.
No history of any epilepsy, asthma, thyroid, coronary artery disease, tuberculosis.
Treatment history
Metformin 500 mg
Glipizide 5 mg
Atenolol 50 mg
Personal history
Attenders said that he is in general a active person.
Diet: mixed.
Appetite: decreased since onset of fever
Sleep: adequate
Bowel: Has not passed stools since Saturday
Bladder: regularly passes urine
Addictions: He said that he drinks once or twice a week about 70 mL.
Last binge was 30 days back.
He also smokes around 2-3 beedis per day. He has been smoking and drinking since the age of 20.
General examination
Patient is conscious coherent and cooperative. Well oriented to time place and person
Pallor absent
Icterus present
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Edema absent
Vitals
BP 122/70
PR 60 BPM
Temp 100 degrees
RR 16 cpm
His hands show a yellowish discolouration
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
INSPECTION
Shape - Scaphoid, with no distention.
Umbilicus - Inverted
No scars, sinuses, engorged veins, no visible pulsations
PALPATION
Soft, non tender
No organomegaly evident
PERCUSSION
Fluid thrill and shifting dullness absent
AUSCULTATION
Bowel sounds present.
CNS EXAMINATION
HIGHER MENTAL FUNCTIONS:
MMSE 24
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : pupillary reflexes present. EOM full range of motion present
5th : sensory intact, motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION:
Right. Left
UL LL UL LL
BULK Normal Normal Normal Normal
TONE Normal Normal Normal Normal
POWER 5/5 5/5 5/5 5/5
SUPERFICIAL REFLEXES:
CORNEAL present present
CONJUNCTIVAL present present
ABDOMINAL present
PLANTAR withdrawal withdrawal
DEEP TENDON REFLEXES:
Right. Left
UL UL
BICEPS 0 0
TRICEPS 2+ 2+
LL. LL.
KNEE 1+. 1+
ANKLE 1+. 1+
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch
pain
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation
CEREBELLAR EXAMINATION:
Finger nose test
Heel knee test
Dysdiadochokinesia
Speech
Rhombergs test
SIGNS OF MENINGEAL IRRITATION:
Kernigs sign, brudzinski sign, neck rigidity
absent
CVS S1 S2 heard, no murmurs
RS Bilateral air entry present, normal vesicular breath sounds are heard in all areas of lungs, no added breath sounds.
Provisional diagnosis
Urosepsis (Acute liver injury and Acute kidney injury)
Diabetes
INVESTIGATIONS
01/12/22
28/11/22
01/12/22
ECGComplete urine examination
26/11/22
TREATMENT:
Inj Pentaz 4.5 gm IV stat
Inj KCL 2 amps in 500 ml NS
Tab doxy 100 mg/po/bd
Tab pan 40 mg/po/bd
Inj optineuron 1 amp in 100m NS
Lactulose
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