A 55 yr old female with Fever and Vomitings

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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

 55 yr old female farmer by occupation came to opd with chief complaints of

   Fever since 5days

   Vomitings since 2 days

History of presenting illness:

Patient was apparantly asymptomatic 20 yrs back then she was diagnosed with hypertension and diabetes on regular checkup.

Since 2 yrs she started developing tingling sensation in both lower limbs.

No history of loss of sensation.

No history of numbness, swelling,joint deformity and pedal edema.

Thereafter 5 days ago she developed fever which is of high grade, intermittent which is associated with chills and rigor and relieved on taking medication.It is not associated with cough ,cold sore throat,shortness of breath and palpitations.

No history of diurnal variation.

After 3 days she started vomiting (more than 5episodes) which is non projectile,non bilious, non blood stained and contents are food particles.

No history of abdominal pain and no passage of stools( due to decreased appetite) , flatulence is passed.No history of blood in stools,No history of hemetemesis, No history of burning micturition.

There was history of headache which of severe type present on temporal and parietal region.No history of photophobia and phonophobia.

History of generalized weakness

Past history:

Known case of diabetes and hypertension since 20 yrs

Not a known case of TB, Epilepsy,Asthma,CAD , thyroid disorders

History of previous surgery for renal calculi (25mm)7 yrs back

History of previous cataract surgery in left eye 6 months back 

Personal history:

Diet : mixed

Appetite: decreased since 5days

Sleep : disturbed

Bowel and bladder movements: previously regular.No passage of stools since 5 Days

No addictions

No drug or food allergies

Family history : No significant family history

Treatment history:

For diabetes(OHA- Metformin and MIXTARD insulin)

For hypertension (Tab Amlong + Atenolol)

General examination:

Patient is concious ,coherent and cooperative

Moderately built and nourished

Vitals:

Temp: afebrile

PR: 74bpm

RR: 18cpm

Bp: 140/80 mmHg 

GRBS: 283mg/dl

No Pallor,Icterus,Cyanosis,Clubbing , Lymphadenopathy,Edema.

Systemic Examination:

CNS Examination:

Higher mental functions:

Patient is conscious,coherent,cooperative,

Speech and language is normal 

Memory is intact

No delusions or hallucinations 

Cranial nerves:Intact

Olfactory nerve 

Optic nerve 

Occulomotor nerve 

Trochlear nerve

Trigeminal nerve

Abducens nerve

Facial nerve

Vestibulocochlear nerve

Glossopharyngeal nerve

Vagus nerve

Spinal accessory nerve

Hypoglossal nerve

Motor system:

                             Right            Left 

 Bulk           UL       n               n      

                    LL        n               n  

Tone           UL        n                n 

                   LL          n               n 

Power        UL         5/5           5/5  

                    LL         5/5           5/5 

Reflexes: 

Superficial reflexes: present

Corneal 

Conjunctival 

Abdominal 

Plantar reflexes 

Deep reflexes:Present

                            Right         Left

Biceps                ++              ++

Triceps              ++               ++

Supinator          ++              ++

Knee                   +              +

Ankle                  +              +

Co ordination present 

Gait normal 

No involuntary movements 

Sensory system:-

Spinothalamic:

                                     Rt                 Lt

 Crude touch              N                   N

  Pain                           N                    N

  Temperature            N                   N

Dorsal column:

  Fine touch                    N                 N

  Joint proprioception  N                N

  Rombergs test.           

  Vibrations:  (in seconds)

      Acromian process.       7.4           7.7 

      Olecronon process.       8.5           8.3

      Styloid process.             8.0.           8.2

      Tibial tuberosity.           5.6           6.0

      Shaft of tibia.                  3.5.           4

      Medial malleolus.           3.5.         4

 Cortical:

Graphesthesia.                N             N

Stereognosis.                   N            N

Romberg's test

Cerebellar signs: 

No nystagmus,Finger nose test positive,Heel knee test positive 

No signs of meningeal irritation. 

CVS Examination:

JVP- Not raised,normal wave pattern.

On inspection:

 shape of chest wall elliptical, no visible pulsations, no engorged veins present.

Apical impulse is not visible

Palpation:

apex beat over left 5th intercostal space medial to midclavicular line. No parasternal heaves

No precordial thrill 

No dilated veins 

Auscultation: S1 and S2 heard no murmurs heard.

Respiratory system:

Chest shape normal  

 Trachea central

Bilateral air entry  Present 

Normal vesicular breath sounds

Per Abdomen :

Soft and non tender

No organomegaly

Bowel sounds heard

Investigations:

Provisional diagnosis:

Viral pyrexia with uncontolled diabetes( bilateral sensory neuropathy in both lower limbs- stocking type)