A 61 year old male with fever and involuntary movements

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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.

5 September 2022

M.Vineela 

2k18

Roll no -90

Case - 

A 61 y/o male, resident of Dubbaka, Ramanapet 

came to the OPD with chief complaint of SOB since 10 days. 

History of presenting illness-  

Patient was apparently alright 3 yrs back then he developed b/l involuntary movements which are asymmetrical(more on right side) and of lesser amplitude and intensity and frequency.

15 days back he developed fever which is of high grade,  intermittent in nature and not associated with chills and rigors. He was treated by the local doctor and the fever subsided in 3 days. 

H/o dry cough since 10 days which is more at night on lying down.

H/o generalized weakness and decreased appetite since 10 days.

H/o SOB since 10 days.( class 2)

H/o burning sensation in the chest during night which is relieved on taking food since 10 days.

He went to private hospital yesterday afternoon where he was diagnosed to have pneumonia.

Past history- 

He is not a k/c/o diabetes,hypertension, tuberculosis, asthma, epilepsy, leprosy, CAD, CVA 

Personal history- 

Diet -vegetarian

Appetite -decreased since 15 days

Sleep -decreased 

B&B movements-regular

Addictions - started consuming alcohol 2 years back(after demise of his wife) and then stopped consuming since 1 year(due to the fear of alcohol affecting his health).

Family history- 

No significant family history 

General physical examination - 

Raised JVP

Systemic examination- 

CVS - 

RESPIRATORY SYSTEM- Position of trachea - central 

Shape of chest - cylindrical

Apex beat- localized at 5th intercostal space

Breath sounds- bilateral inspiratory crepts  

in bilateral subclavicular,mammary and infra axillary areas

Egophony present. 

P/A - soft non tender

 Mild hepatomegaly and spleenomegaly present .

CNS - 

Oriented to time, place and person

Able to recall events but there is delay in response 

Speech is normal

No cranial nerve deficits 

No loss of power 

Tone -  more increased on right upper limb 

??Cog wheel rigidity

Hyper reflexia of biceps, triceps, supinator 

2+ for knee reflex

Absent b/l ankle reflex

B/L plantar withdrawal +

Tremors in both limbs &/ hands which is pill rolling type, coarse and static 

Palmo mental relfex- present.