A 60 year old male patient was brought to casualty with high fever , weakness of upper left limb .

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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 the case of a male farmer , residing in Pathelapalem , Suryapet .

CHIEF COMPLAINTS:

        - high fever ( 10days ) 

        - weakness of upper left limb (10 days )

        - dry cough from 2 days 

        - burning micturition since 2 days 

HISTORY OF PRESENTING ILLNESS:

    

    Patient was apparently asymptomatic 10 days back , he had high grade fever 10 days ago with chills and rigors .

   - H/O dry cough ( 2 days ) 

   - weakness in the upper left limb which is sudden in onset .

   - H/O decrease micturition from 1 week 

 

PAST HISTORY: 

   Patient was admitted in Miriyalguda private hospital for the same , was treated with medication .

 - H/O diabetes since 10 years 

- H/O loose motions for 3 days ( while in the Miriyalguda hospital) 

 -H/O HTN since 10 years 

 -N/H/O CAD , Asthma , TB , Antibiotics, Radiation , blood transfusion, surgeries . 

PERSONAL HISTORY: 

 Mixed diet 

 No addictions to alcohol, tobacco , drugs , beetle leaf . 

 No significant family history 

 GENERAL EXAMINATION: 

  

Patient is conscious , coherent and cooperative.

Pateint is examined in a well lit room with consent .

 

Slightly pallor 

No 

Slightly pallor

VITALS:

Temperature- 98.4°F 

BP-120/70 mmhg

PR-82bpm

RS-BAE+

No associated pain

SYSTEMIC EXAMINATION:

CVS- S1S2 heard and no murmurs heard.

INVESTIGATIONS :