General Medicine
A 40 year old male came to OPD with the complaints of high grade fever and chills.
23,AUGUST,2022
E LOG GENERAL MEDICINE
Hi, I am Pindi Gayatri , 3rd Sem Medical Student.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-centered online learning portfolio and your valuable inputs on the 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.
CHIEF COMPLAINTS
A 40 year old male came to GM-OPD With the complaints of fever since 5 days associated with chills and rigors on 22nd,August.
Headache,Nausea,Generalised body pains.
HISTORY OF PRESENT ILLNESS
He came to hospital with the complaints of high grade intermittent fever associated with chills and rigors-relieved on medication.
Vomiting and Nausea since 4 days.
Bilateral lower limb weakness since 4 days.
Associated with generalised weakness and calf muscle pain since 4 days.
Cold and dry cough since 4 days.
He had a fracture of the hand 4-5 years ago,rod is put in the hand(right arm).
When he had fever he went to the nearby hospital for checkup and used the prescribed medications for 2-3 days.During this he had a drug allergy to particular medicine which is subsided by the usage of other medicine prescribed by the doctor.
HISTORY OF PAST ILLNESS
It is not a known case of Hypertension, CAD, epilepsy, Asthma, Tuberculosis, Thyroid disorders etc.
TREATMENT/DRUG HISTORY
No Diabetes
No hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No chemo/Radiation
No Blood transfusion
PERSONAL HISTORY
Married
Occupation-steel labourer
Diet-mixed
Appetite -normal
Bowels-regular
Micturition-Normal
Habit/addictions-alcohol occasionally
Start:20 years(180 ml)
Stopped:6 years ago.
FAMILY HISTORY
No Diabetes
No hypertension
No Heart disease
No stroke
No cancers
No tuberculosis
No asthma
GENERAL EXAMINATION
No pallor
No icterus
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITAL SIGNS
Temperature-99.6°F
Pulse rate-92/min
Respiratory rate -18/min
Blood pressure -110/70 mmHg
Spo2-98%at room air
GRBS-116 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds heard
No dyspnea
No wheezing
ABDOMEN
Shape of the abdomen-scaphoid
No tenderness
No palpable masses
Normal hernial orifices
No free fluid
No bruits
Non palpable liver
Palpable spleen-spleenomegaly
Bowel sounds are heard
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Cranial nerves ,motor system-intact
Glassgow scale-15/15
Reflexes
Biceps Triceps supinator knee ankle
Right ++ ++ ++ ++ -
Left ++ ++ ++ ++ -
Plantars-flexor
Cerebellar Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
On 23rd of August
Blood transfusion
Investigation result chart
TPR Graphic sheet
