THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome
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.
3- March-2022
50 years old female came to the OPD with chief complaints of
Fever since 4 days
Burning micturition since 2 days
Abdominal distension since 4 days
Vomiting and diarrhea since 4 days
HISTORY OF PRESENT ILLNESS
She was apparently asymptomatic 4 days back then she developed fever associated with chills , rigor and it was mostly occuring during night, subsided as taken medication.
Vomitings were non bilious, non projectile and contained food and water particles , associated with diarrhea.
No c/o Cold, cough , shortness of breath, bilateral pedal edema , headache , giddiness
PAST HISTORY :
Not a known case of diabetes mellitus , hypertension , Epilepsy , TB , CAD , CVA
Was found to be HIV positive 13 years ago, HAART was initiated for 6 months then stopped
Was diagnosed having borderline leprosy due to hypopigmented patches noted in flexors of arm. MDT therapy was taken for 6 months, 11 years ago.
( Referal to dermat)
Tubectomy was done 25 years ago.
PERSONAL HISTORY:
Diet : Mixed
Appetite : Normal
Sleep : Disturbed
Bowel and Bladder moments : Regular
Micturition : Normal
FAMILY HISTORY:
Not significant
CNS : NAD
Abdomen: Distended
INVESTIGATIONS
Haemogram
ECG
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