A case of 60year old female

Name: J. Akash

31/12/2022

Roll no. 53

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.

Following is the view of my case :

patient complaining of fever since 4days

decreased apetite since 4days

difficulty in micturition since 4days

patient was apparently asymptomatic 10years back

then she had H/O bleeding from nipples following diagnosed to have ?fibroadenoma, surgery was done and removed,post op uneventful

5years back patient had swelling at sacral area progressively increased in size, surgical removal was done,post op uneventful

2yeara back patient developed tingling and numbness of B/L upperlimbs and lowerlimbs and was investigated and used medications and was subsided

weakness of upperlimbs and lowerlimbs gradually progressive

1year and 7months back patinet was unable to walk and difficulty in grip,used to walk with support for 4months later weakness progressed and was unable to walk

7months back patient developed pedal edema, burning sensation of feet, investigated to jave compressive myelopathy with spastic qaudriparesis

planned for cervical laminnectomy

1and half month back surgery was done

post surgery patient had difficulty in moving Rt upperlimb, slowly recovered

burning, tingling sensation reduced,pain reduced

tone slightly improved, decreased bowel and bladder movements

4days back patient developed fever highgrade intermittent

No H/O cough,cold, burning micturition , sore throat

H/o abdominal distension,blanching,retrosternal burning sensation

since 4days difficulty in passing urine, decreased urination , unable to pass urine without strain

No H/O hesitancy, urgency, incontinence, increased frequency

voiding of urine and sensations are normal

PAST HISTORY:

Not a k/c/o DM,HTN,TB, EPILEPSY,ASTHMA,CAD

FAMILY HISTORY: insignificant

GENERAL EXAMINATION

pt conscious, coherent, co-operative well orientated to time ,place, person

no signs of pallor, icterus, clubbing,cyanosis,edema,lymphadenopathy

CVS- S1S2+,no thrills and murmurs

RS-trachea,BAE+,NVBS

ABDOMEN:soft,nontender,no palpable mass,liver and spleen not palpable

CNS: pt conscious

speech-normal

no meaningeal signs

INVESTIGATIONS:

Neck Xray C spine

Chest Xray:

USG abdomen

investigation chart:

Diagnosis:

Pyrexia under evaluation ?UTI

with post cervical laminnectomy

with hyponatremia under evaluation

with hypokalemia under evaluation

Treatment Given

IVF NS @100ml /hr

1amp KCL +500ml NS

Inj.neomol 1gm/IV

31/12/2022

UNIT 5

DR HIMAJA, PGY1

DR PAVANI, PGY2

DR SAI CHARAN, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN

AMC, DAY 1

AGE : 60Y GENDER :F

No fever spikes

stools passed

pt conscious, coherent, co-operative

Bp-120/70mmhg

PR-82bpm

Temp-98°FF

GRBS-187 mg/dl

SPO2-97%

CNS-HMF intact

memory -normal

Tone : RT LT

UL N. decreased

LL N. decreased

REFLEXES: B. T. S. K. A. Plantar

RT. + + ++ . ++ + + extension

LT. - - - ++ + + extension

power LT RT

UL. 5/5. 2/5

LL. 5/5. 4/5

pyrexia secondary to ?UTI

with post laminnectomy done(1and half month back)

with hyponatremia (resolved)

with hypokalemia 2° to ? renal loss

IVF NS @100ML/HR

inj.neomol iv/sos

(D1 )Tab nitrofurantoin 100mg po/bd

Syp. POTCHLOR 15ml/po/Tid

monitor vitals

01/01/23