77 year old male with Fever, Abdominal bloating and cough.

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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.

  77 year old male came to opd with chief complaints of

-Fever since 6 days

-Abdominal discomfort since 3 days

-Cough since 3 days

HOPI:-

Patient was apparently asymptomatic 6 days ago. Then he developed fever which is sudden , intermittent (increased at nights).It is associated with chills and relieved temporarily by medication. 

3 days back suddenly he lost his  consciousness , all limbs were stiff , uprolling of eyes , frothing from the mouth is seen and passed urine.Then he was immediately taken to the hospital where he regained his consciousness after half an hour.

On the same day he started complaining cough with sputum which is whitish in colour and non blood stained.He also complained about dryness of mouth, abdominal bloating and burping.Then he was admitted in our hospital as his condition was not improving.

DAILY ROUTINE:

He wakes up at 7am and takes his breakfast by 9 am(rice +chicken) and the he goes to work(labourer) by 10am.

He takes his lunch by 1 PM. He usually takes rice and chicken.

He come home by 4 pm and takes tea + biscuits.

He has his dinner by 6pm and goes to bed by 9pm.

PAST HISTORY:-

Patient is a known case of DM since 7 months and he is on medication.

He is not a known case of TB, HTN , Asthma , Epilepsy and thyroid abnormalities.

 3 yrs back he had undergone a surgery (cholecystectomy)

PERSONAL HISTORY:

Diet: mixed

Appetite: decreased

Sleep: adequate 

Bowel and bladder movements: decreased

No addictions.

FAMILY HISTORY: No significant family history 

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative, moderately built and moderately nourished.

Well orientated to time ,place and person

Moderately built and nourished 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

uvula is bent

VITALS:

Temperature: afebrile

Pulse: 80 beats/minute

Blood pressure:100/70mm Hg

Respiratory rate: 16 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS: bilateral air entry present, right infraclavicular wheeze is present and right infrascapular crepts are present.

CNS: No focal neurological deficit.

Abdomen: soft and non tender, bowel sounds are present

INVESTIGATIONS:-

Provisional diagnosis:

Pyrexia under evaluation of pancytopenia and history of one episode of seizure?