Burning sensation since 1 week, fever since 1 day

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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.

Chief complaints :

  Patient came with cheif complaints of burning type of sensation of whole body since 1 week.

Fever since 1 day

HOPI : 

Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).

He also have complaints of fever since today afternoon associated with chills , relieved on medication.

H/o of burning micturition since 4-5 days 

No H/o decreased sensations

No h/o bowel and bladder incontinence.

No h/o seizure activity

No H/O cold, cough, sore throat

No H/o nausea , vomiting, pain abdomen

No H/o loose stools

PAST HISTORY :

Not a k/c/o DM , HTN , thyroid disorders, asthma, epilepsy

GENERAL EXAMINATION:

Patient is conscious, coherent

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

Temp: 101.5 degree F

Pr: 98bpm

Rr: 20cpm

Bp:130/70mm Hg

Grbs:151mg/dl

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-

No local rise of temperature

No tenderness

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Chest movements : equal on both sides

Vocal fremitus same on both sides in all areas

Percussion -

Resonant in all areas on both sides

Auscultation -

BAE +ve

NVBS on both sides 

Vocal resonance same on both sides

ABDOMEN:

Shape - Scaphoid

No tenderness, palpable mass, No Fluid

No bruits 

Liver not palpable

Spleen not palpable

Bowel sounds heard 

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

CNS:

Pt is Conscious ,coherent, cooperative

Speech normal

Cranial nerve examination normal

Tone     UL    LL

Right     N         N 

Left        N         N

Power :        UL LL

Right           2/5 4/5

Left             3/5 4/5 

Reflexes - B T S K A P 

RT- +3 +3 2+ 3+ 3+ F

LT- +3 +3 2+ 3+ 3+ F

INVESTIGATIONS:

4/6/23 -

5/6/23 -

6/6/23 -

DIAGNOSIS:

  Pyrexia under evaluation with cervical laminectomy 2 months back

TREATMENT:

1. Inj Neomol 1 GM iv/sos ( if temp > 101 F)

2. Inj Monocef 1 GM iv/ bd

3. Inj optineuron 1 amp in 500ml NS /OD

4. Tab dolo 650mg Po/ Sos

5.tab pregabalin 75mg po/Hs