70/M WITH FEVER SINCE 4DAYS AND DRY COUGH SINCE 4DAYS



Unit 3 admission:
Interns-
Jeeharika
Archana
Harsha
Kalyan
Sreeja


Dr.Raveen PG1
Dr.vaishnavi PG2
Dr.Vamshi PG3
Dr.Aravind PG3

Dr.Hareen SR
Dr.Praveen Naik Ass.Prof


70year old male presently staying at home,r/o pochampally,was apparently alright 8days ago,then patient son met with an accident (sustained multiple fractures). patient is in grief about it and used to visit his son 3days ago,patient had an episode of syncope lasting for 2-3mins .Later he woke up and did his daily routine activity(like cooking ).Patient lives with his wife who is also not well.since next day ,patient was in altered state ,having irrelevant talk ,associated with involuntary passage of urine.H/O pricking movements present.

Patient is able to walk on his own till yesterday.No H/O seizures ,ENT bleed ,head trauma ,No h/o weakness .
Since morning patient is unable to walk on his own ,associated with stiffness of limbs (b/l UL and LL).patient is in altered state.Not oriented to time,place and person.

C/o fever since afternoon,high grade,intermittent.Not associated with chills

No h/o headache,vomitings,loosestools, pain abdomen ,burning micturition.

C/o intermittent dry cough since 4days 
No h/o SOB,chest pain, palpitations.

Not a k/c/o DM,HTN,asthma,cad,TB.
 
Vitals:
Temp:102F
PR:110bpm
BP:120/70mmhg
SPO2:94% at room air
GRBS:103mg
 
CVS:S1S2 +,No murmurs
RS: NVBS,BAE+
P/A: SOFT,NON TENDER
CNS: Patient is not oriented to time/place/person .
Speech-slurred 
Tone:.         Right.           Left 
        UL.     Increased.     Increased
        LL.      Increased.     Increased
   Power : 
              Right.              Left 
              3/5                 3/5(couldnot be elicited)
                      
Reflexes 
                             Right.                     Left
Biceps.                  0                            0
Triceps.                  +                         +
Supinator.              0                          0
Knee.                      +3                         +
Ankle.                     0                           0
Plantar:.         Withdrawal        withdrawal

INVESTIGATIONS:
Diagnosis:
 LEFT LOWER LOBE PNEUMONIA WITH THROMBOCYTOPENIA.



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