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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
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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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
An 85 year old male came to hospital with chief complaints of :
CHIEF COMPLAINTS
• Fever since 3 days
• 2 episodes of involuntary movements of upperlimb and lower limb in the past 3 days
• Loose stools since 1 day
HOPI
Patient was apparently asymptomatic 3 days back then he developed fever of High grade with chills , following which he developed seizures which lasted for 2 mins associated with confusion (irrelevant talk ) for 5 mins, during seizures episode he had involuntary micturation and passage of stools . He consulted local RMP ,there he was treated
with some medications and sent back to home .
The following day he had a similar episode again.
After the 2nd episode of seizure activity i.e on the 3rd day of illness, he came to the hospital with passage of loose stools (not Blood tinged , non foul smelling, sticky )
PAST ILLNESS
Not k/c/o HTN , DIABETES, ASTHAMA ,TB , EPILEPSY, CVD
PERSONAL HISTORY
No addictions
micturation : unable to hold urine
Loose stools
Sleep : Regular
GENERAL EXAMINATION
Patient is conscious and coherent
Pallor -Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy- Absent
VITALS
Pulse rate : 92
Temp : 99°F
RR : 21
BP : 100/70 mmHg
SYSTEMIC EXAMINATION
• CVS
s 1 s 2 heard
no added sounds
• RESPIRATORY SYSTEM
Position of trachea central
Chest symmetrical
Chest expansion symmetrical
R L
percussion resonant resonant
Auscultation normal normal
Abdominal examination
abdomen is soft ,Non tender , no Ascites
CNS Examination
Higher mental function : intact
Cranial nerve examination : normal
MOTOR SYSTEM
•Muscle Bulk. R L
Inspection. Normal Normal
Palpation. Normal Normal
•Muscle tone
upper limb Normal Normal
lower limb Normal Normal
•Muscle power
upper limb 5/5 5/5
lower limb 5/5 5/5
•Reflexes
Biceps ++ ++
Triceps. ++ ++
Supinator. ++ ++
Ankle ++ ++
Knee ++ ++
Plantar ++ ++
SENSORY SYSTEM Normal
INVESTIGATIONS
MRI BRAIN
ULTRASOUND
2D ECHO
CHEST XRAY
DIAGNOSIS
Febrile delirium (with 2 episodes of gtcs), dengue ns 1 positive with throbocytopenia, Non diabetic and non htn
TREATMENT
IVF NS ,RL @ 75 ml/hr
TAB.LEVIPILL 500 MG / PO / BD
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