Medicine Case Discussion
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Thursday, 3rd June,2021
A 50yrs female with fever and loss of sensation over left leg from mid calf region till foot
B.Sushma ,8th semester
Roll no.154
June 3,2021
A CASE DISCUSSION ON FEVER, LOSS OF SENSATION OVER LEFT LEG
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.
Following is the view of my case :
Case admitted under unit 2
History was taken by Dr.A. Vaishnavi Mam PG y2
and helped by the interns
- G.Sai Vittal Sir
- Ch.Rishik Sir
- G.Preethi Mam
CASE PRESENTATION:
A 50 yr old female, farmer by occupation presented to our opd on 31st May 2021 with
CHEIF COMPLAINTS of
- Loss of sensation ,Numbness over left leg- from mid calf to toes since 3 years .
- Fever with chills and bodypains since 6months.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3years back later on she developed-
1) Pain and tingling over left lower leg - that lasted for 1 month , for which she used medications .
Later she developed loss of sensation , numbness over left leg- from mid calf to toes since 3 years . Insidious onset ,non progressive .
patient is unable to differentiate between hot and cold , unable to perceive pain sensation .
History of repeated trauma's to left foot - un noticed by her ,unable to feel her clothes , anklet , slippage of chappal on left side .
No weakness,no hyperasthesia,no tingling.
No bowel and bladder disturbances.
Since then patient is taking wysolone 10/20mg tablet bed time daily and also pregabalin tablets.
2)Fever since 6 month's ,High grade with chills and bodypains .
Fever relives only with IV injections for 2 days ,later recurs and lasts for 2-3 days .
She is complaining of loss of appetite and weight loss since 6 month's .
She had multiple hospital visits for fever , where investigations were showing high TLC count -around 20k-29000, smear for MP negative,Widal negative, IgM weak positive-although no thrombocytopenia .
History of UTI 6 months back
History of Tinea corporis infection .
Negative history:No cold ,no cough ,no pain abdomen ,no burning micturtion ,no urinary urgency, frequency ,no vomitings ,no loose stools ,no headache ,no joint pains ,no early mrng stiffness ,no rash .
PAST HISTORY:
- History of hypopigmentation over the leg 2years back.
- Known diabetic since 2 years on Glimi M2 / once dialy.
- Not a known HTN ,Asthma , Epilepsy ,CAD.
PERSONAL HISTORY:
Appetite: Decreased
Diet: Mixed
Bowel and bladder movements: Regular
Addictions: Drinking cheap liquor(Occasionally after work).
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
She is well oriented to time, place and person.
She is moderately nourished.
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Edema
VITALS:
Temperature: Afebrile
Pulse Rate: 102 beats per minute
Standing
Bp: 130/90 mmHg
Pulse rate: 120 beats per minute
Supine
Bp: 130/90mm of Hg
Pulse rate: 104 beats per min
Fever chart:
June 1st
2PM
Temperature: 98.6F
Pulse rate -98 bpm
Respiratory rate - 23 cpm
Bp: 110/80mmHg
SpO2- 98%
4PM
Temperature : 98.6F
Pulse rate -94bpm
Respiratory rate - 22cpm
Bp: 110/80mmHg
SpO2- 98%
6PM
Temperature : 98.6F
Pulse rate -82bpm
Respiratory rate - 23 cpm
Bp: 110/80mmHg
SpO2- 96%
8PM
Temperature: 98.6F
Pulse rate -94bpm
Respiratory rate - 19cpm
Bp: 110/80mmHg
SpO2- 98%
10PM
Temperature:98.6F
Pulse rate -92bpm
Respiratory rate - 19cpm
Bp: 110/80mmHg
SpO2- 97%
June 2nd
12AM
Temperature:96.4F
Pulse rate : 92bpm
Respiratory rate : 22cpm
Bp : 110/80 mmHg
SpO2: 98%
2AM
Temperature:98.6F
Pulse rate : 94bpm
Respiratory rate : 20cpm
Bp : 110/80mmHg
SpO2:98%
4AM
Temperature:97.6F
Pulse rate : 92bpm
Respiratory rate : 19cpm
Bp : 110/80mmHg
SpO2:98%
6AM
Temperature-98.6F
Pulse rate-96bpm
Respiratory rate-20cpm
Bp-110/80mmHg
SpO2-99%
8AM
Temperature-99.6F
Pulse rate-97bpm
Respiratory rate-19cpm
Bp-120/80mmHg
SpO2-98%
10AM
Temperature:98.6F
Pusle rate:87bpm
Respiratory rate -20cpm
Bp-120/80mmHg
SpO2-97%
12PM
Temperature:98.6F
Pulse rate:92bpm
Respiratory rate-19cpm
Bp:120/80mmHg
SpO2:96%
2PM
Temperature:97.6F
Pusle rate:89bpm
Respiratory rate:24cpm
Bp:120/80mmHg
SpO2:96%
3PM
Temperature:98.6F
Pusle rate:90bpm
Respiratory rate:20cpm
Bp:110/80mmHg
SpO2:99%
SYSTEMIC EXAMINATION:
Respiratory System- BAE+ clear
CVS- S1 and S2 heard
CNS-
Higher mental functions intact
Cranial nerves intact
Motor system -
Right left
UL - Tone- N N
LL -. Normal. Normal
Power -. 5/5. 5/5
Reflexes -.
B +1. +1
T +1. +1
S. +1. +1
K. +2. +2
A. -. -
P. Flexor. Mute
Sensory system -
Vibration:
UL - Wrist - 8.3. 7.3
Elbow - 6.97. 8 sec
LL - Ankle - 8.58 Absent
Knee -. 6.68 6.9 sec
Joint position
UL - intact. Intact
LL - great toe lost lost
Pain + -
Touch + -
Temp + -
Romberg's - intact
Cerebellum --- no incordination
Clinical pictures:
Multiple annular scaly erythematous plaques noted over the abdomen on right side lower back
INVESTIGATIONS:
Complete Blood Picture:
Where investigations were showing
- High TLC count - around 20k -29000
- Smear for MP negative
- Widal negative
- IgM weak positive - although no thrombocytopenia .
Complete Urine Examination:
Random Blood Sugar:
Provisional diagnosis -
Peripheral neuropathy -chronic - Pure sensory ,assymetrical - Left lower leg ( mixed both large and small fiber neuropathy )
Steriod induced hyperglycemia ( HbA1c-7 )
Tinea corporis
Fever under evaluation- UTI
Pure neuritic form of Hansen's
TREATMENT:
Tab: Glimi-M2/CO/OD
Tab: Wysolone 10mg/PO/OD
Tab: DOLO 650mg /PO/SOS
GRBS Charting 6th hrly
Temp Charting 4th hrly
Inj Optineuron 1amp in IONs/IN/OD
Tab TECZINE 5 mg
LULIFIN cream I/A BD x 2 weeks
I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this oppurtunity and thankyou Dr.A.Vaishnavi Mam(P.G,General Medicine)for the guidance.
