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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is 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 a diagnosis and treatment plan.
Name :- Kattekola Sathwik
Roll no 75
Case Report
Patient came to casuality with c/o fever sonce 2 days and cough since 2 days
History of Presenting Illness:-
Patient was apparently normal 2 days ago then he had fever which was insidious in onset gradual in progression ,high grade, intermittent,associated with chills and Rigors and relived on medication
C/o Cough with expectoration since 2 days whitish mucoid sputum ,non blood tinged,no foul smelling
No h/o Nausea, vomiting, pain abdomen, SOB,Loose stools,Burning micturition
C/o Generalised weakness since 2 days
PAST HISTORY
Not a K/C/O DM , HTN, ASTHMA, TB, EPILEPSY, CVA, CAD, THYROID DISORDERS
Personal History
He is a student
Appetite :- normal
Diet :- Mixed
Bowel and Bladder :- Regular
Sleep :- Adequate
Addictions :- nil
Family History
No similar complaints in Family
General Physical Examination
Patient is C/C/C
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
Temperature : 101.5 F
PR:- 110 bpm
RR:- 20cpm
Spo2 :- 100 % @RA
GRBS :- 88mg%
CVS :- s1s2 + no murmurs
RS:- BAE+ NVBS HEARD
PA:- SOFT NT
CNS :- NFND
Investigations
Chest X Ray
HEMOGRAM
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