60 year old female with PYREXIA SECONDARY TO UTI

January 01, 2023

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.

Chief complaints:

patient complaining of fever since 5 days

difficulty in micturition since 5 days

History of presenting illness:

patient was apparently asymptomatic 5days back then she developed fever which is insidious in onset and intermittent in nature which aggravated during night and relieved on medication associated with generalised weakness and not associated with chills , rigors , cough, cold, headache, night sweat.

H/O burning micturition

No H/O sore throat ,vomitings

since 5days difficulty in passing urine, decreased urination ,unable to pass urine without strain.

Past history:

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

10years back she had H/O bleeding from nipples , surgery was done.

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

2 years back patient developed tingling and numbness of lowerlimbs and used medications and was subsided.weakness of upperlimbs and lowerlimbs gradually progressed

1year back patient was unable to walk ,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 compressive myelopathy with spastic qaudriparesis

planned for cervical laminnectomy

1and half month back surgery was done

burning, tingling sensation reduced,pain reduced

4days back patient developed fever.

Personal history :

Diet: mixed

Appetite: decreased appetite

Sleep: inadequate

Bowel : decreased bowel movements since 5 days

Bladder:difficulty to void

No addictions

FAMILY HISTORY:

Not significant

Daily Routine:

She usually wakes up in the morning around 7 am ,she drinks tea around 8 am ,doesn't have breakfast.She will have lunch around 12 in the noon with rice and vegetable curry in her meal.She takes a nap in between 1 pm to 3 pm. She will have fruits around 4pm.Then she ll have her dinnerby 8pm .She will go to bed by 9 pm.she stays on the bed for whole day.

GENERAL EXAMINATION

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

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

Vitals:

Temperature:98•F

Pulse:64bpm

BP:130/80

RR:15cpm

SYSTEMIC EXAMINATION:

CVS- S1S2+,no murmurs heard

RS-trachea central,BAE+,

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