MEDICINE CASE DISCUSSION
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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
55 year old male patient presented with pyrexia secondary to urosepsis(pseudomonas infection) with h/o cervical laminectomy 2months back.
CHIEF COMPLAINTS:
Patient came with chief complaints of burning type of sensation of whole body since 1 week.
Fever since 1 day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).
He also have complaints of fever since today afternoon associated with chills , relieved on medication.
H/o of burning micturition since 4-5 days
No H/o decreased sensations
No h/o bowel and bladder incontinence.
No h/o seizure activity
No H/O cold, cough, sore throat
No H/o nausea , vomiting, pain abdomen
No H/o loose stools
PAST HISTORY:
Not a k/c/o DMII,HTN, thyroid disorders, asthma ,epilepsy
H/O cervical laminectomy done 2 months back.
FAMILY HISTORY:
Insinificant
PERSONAL HISTORY:
DIET-mixed
APPETITE-normal
BOWEL AND BLADDER-burning type of micturition since 4 days
SLEEP-adequate
ADDICITIONS-occasional alcoholic and smoker
ALLERGIES-none
GENERAL EXAMINATION:
Patient is conscious, coherent,coperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS:
Temp: 101.5 degree F
Pr: 98bpm
Rr: 20cpm
Bp:130/70mm Hg
Grbs:151mg/dl
FEVER CHART:
SYSTEMIC EXAMINATION
CVS:S1 S2 heard , No murmurs
RS: BAE +, NVBS
P/A: NT ,No organomegaly
CNS:
Tone UL LL
R N N
L N N
Power : UL LL
R 2/5 4/5
L 3/5 4/5
Reflexes - B T S K A P
RT- +3 +3 2+ 3+ 3+ F
LT- +3 +3 2+ 3+ 3+ F
INVESTIGATIONS:
4/6/23
5/6/2023
6/6/23
CUTURE REPORTS:
PROVISIONAL DIAGNOSIS: Pyrexia secondary to urosepsis (pseudomonas positive) with h/o cervical laminectomy 2 months back.
TREATMENT:
1. INJ NEOMOL 1 GM IV/SOS ( if temp > 101 F)
2. INJ MONOCEF1 GM IV/ BD
3. INJ OPTINEURON 1 amp in 500ml NS IV /OD
4. TAB DOLO 650mg PO/ SOS
5.TAB PREGABALLIN 75mg PO/HS
6.INJ PIPTAZ 4.5MG IV/TID
TYPES OF FEVER:
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