58 yr old male patient with Shortness of breath , Sweating and fever.

July 06, 2022

58 yr old male patient with Shortness of breath , Sweating and fever.

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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.

58 yr old male patient was admitted with chief complaints of Shortness of breath , Sweating , fever.

HOPI :-

Sequence of events:-

Patient was apparently asymptomatic 7 yrs back then he went to checkup for fever then was diagnosed as Diabetic and aslo with hypotension and was taking medications since then.

Then after 2 yrs he developed ulcers on both the legs after an injury during the field work and there was skin peeling also.

Thereafter he was on a diet for 4 months {which includes drinking organic coconut oil,taking only liquid foods, Vegetables that made him lose his weight (100 to 75 kg)} was healthy but he developed skin infections (fungal) on the lower abdomen and legs and was on medications.

After a year he developed muscle spasm in the left leg and back pain for which he took various unprescribed painkillers (for 2yrs).he also went for physiotherapy 5-6 months back.

3 months back he met with an RTA and had an left ankle injury which was non healing even on medication.

Patient was alcoholic at the age of 15-30 yrs and stopped drinking thereafter.

8 yrs back he again started drinking alcohol due to depression after his son died and stopped when he developed leg ulcers(5 yrs back).

1yr back he consumed alcohol 2-3 times and stopped.

5 days back he started consuming toddy ( after dinner) daily for 3 days.First 2 days he was normal but on the 3rd day before going to sleep at night he started having shortness of breath ( grade 4 ), Sweating, fever and gas trouble.

He was treated by private practitioner on the same night but his condition was not improving so was shifted to the hospital.

Past history:

K/c/o Diabetes and hypotension

Not a k/c/o Asthma,TB, Thyroid disorders, Epilepsy

Personal history:

Diet:mixed

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: regular

Family history: No significant family history

GENERAL EXAMINATION:-

Patient is conscious coherent and cooperative