This is an online E logbook 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 an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.
I’ve 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"
20-8-2022
A 50-year-old female patient came to the casualty with the cheif complaints of fever and swelling of both the legs since 3 days.
History of present illness :
H/o Fever-
Onset - insidious
Duration- since 4 days
Type - intermittent
Associated with chills and rigors.
Diurnal variation present
Increased temperature at night
H/0 constipation for 2 years
Passes stools once every 3 days
H/0 loose stools 4 days back
6 episodes
Non-blood stained
Mucus is present.
Bilateral pedal edema since 3 days
Pitting type
Burning micturition present
No history of shortness of breath
Past history
Not a known case of,
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
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
He is examined in a well lit room, with consent taken.
He is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Vitals : on the day of admission (20/8/2022)
Temperature - Afebrile
Pulse rate - 96 bpm
Respiratory rate - 16 cpm
Blood pressure - 120/70 mmHg
SpO2 - 98% on Room air
GRBS - 101 mg/dl
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 :
On the day of admission (20-8-22)
X Ray
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