60 year old male came to gm OPD with chift COMPLAINTS of pyrexia

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

Case Report-

A 60yr old female resident of Narketpally agriculture labourer by occupation came to GM OPD with

CHIEF COMPLAINTS

Fever since 4 days 

Decreased micurition since 4 days

History of Presenting Illness

Patient was apparently asymptomatic then she developed high grade fever 4 days back intermittent in nature not associated with cold cough and no burning micurition but decreased micurition was seen.

5 years ago patient had selling at sacral region which increased progressively in size (not measured),no disturbance in power and tone of muscles and bowel and bladder were regular

2 years back patient  patient developed tingling and numbness of upper 2 limbs and lower 2 limbs, medications was used (drug -unknown,dose-unknown) and upon using medication it did not subscide.

 Weakness of limbs was progressive and tingling sensation was progressive and had burning sensation.

Patient was unable to walk without support since 6 months and complete bed ridden since 3 months

6 months ago patient developed pedel oedema from ankle to thigh region and due to this patient sleep cycle was altered.

On investigation it was concluded of compressive myelopathy where surgical laminectomy was done

Post surgery patient was feeling better and the symptoms of tingling and numbness reduced

Patient was not able to lift hands till 1 wk of post surgery.

Past history

No similar complaints in the past.

Treatment history  

Laminectomy done 6 months ago

Personal history

Diet:- mixed

Appetite - decreased 

Sleep:- not adequate

Bowel and bladder:- decreased urinary output and constipation 

Addictions:- NIL

Family history

No significant family history

Obstetric history

G4 P3 A1 L3

Delivered through FTND

Allergic history

No known allergies to drugs and other foods

General examination

Patient is conscious coherent and cooperative.

Weakly built and weakly nourished

 Tempurature-98 c

 Pulse rate -82 bpm

Respiratory rate- 15cycles per min

BP -130/80 mmhg

CNS memory intact

Pallor  present

Icterus no

Clubbing no

Lymphedenopathy-No

Edema No 

Cyanosis No

Systemic examination

CVS- S1 and S2 heard no murmurs

Respiratory system

Bilateral aur entry present

Per abdomen

Abdominal distention seen

CNS

FINGER NOSE TEST -No coordination

Provisional diagnosis

Pyrexia with suspection of UTI 

 Reflexes

Investigation

Pallor-

no.signs of icterus

ECG

CLINICAL DIAGNOSIS 

Pyrexia secondary to UTI

TREATMENT

IVF NS @100ML/HR

inj.neomol iv/sos

(D2 )Tab nitrofurantoin 100mg po/bd

Syp. POTCHLOR 15ml/po/Tid

monitor vitals