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
19-08-2022
A 45 year old female came to OPD with cheif complaints of
Fever with chills since 10 days
Headache since 10 days
Generalized body pains since 10 days
Shortness of breath since 5 days
Decreased appetite since 3 days
History of present illness
Pt was apparently asymptomatic 10 days back then she developed fever with chills, intermittent in nature that relieved on medication.It was associated with headache, generalized body pains. Since 5 days pt had complaints of SOB on exertion which gradually progressed to grade II/II
No h/o chest pain, palpitations, syncope attacks
No hlo pedal edema, burning micturation and decreased urine output
No signs of any bleeding manifestations
Past history
N/K/C/O DM/HTN/TB/ASTHMA/CAD
Personal history :
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and Bladder movements - regular
Addictions - no
No known allergies
Drug history :
No significant drug history
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person at the time of examination
She is examined in a well lit room, with consent taken.
She is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Pedal edema - absent
Vitals :
Fever subsided
Temp 98 F
PR: 90bpm
BP110/70mmHg
RR 30cpm
Systemic examination :
CVS : S1 and S2 heart sounds heard
No murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present position of trachea - Central
Vesicular breathsounds heard
CNS : intact
ABDOMEN : Soft and non tender
No palpable masses
Bowel sounds heard
No organomegaly
Investigations
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