General Medicine
A 50 year old male with fever,headache and cough.
26,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 50 year old male came to the casuality with complaints of fever since 5 days,headache since 4 days, vomitings since 2 days and body pains since 1 day on 25th, August.
HISTORY OF PRESENT ILLNESS
He came to the casuality with the complaints of fever (high grade)associated with chills and rigors on/off since 4 days.
Generalised weakness since 4 days.
Headache since 4 days in the frontal region.
Body pains since 4 days.
Dry cough since yesterday.
HISTORY OF PAST ILLNESS
Not a known case of hypertension, Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.
TREATMENT/DRUG HISTORY
No Diabetes
No hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No Chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Married
Occupation-farmer
Diet-mixed
Appetite-normal
Bowels-regular
Micturition-normal
No known Allergies
Habits/addictions - alcohol-regular
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITALS
Temperature-97°F
Pulse rate-100bpm
Respiratory rate-16 cpm
Blood pressure-80/60 mmHg(left arm)
SpO2 at room air-95%/at RA litres of 02
GRBS-155 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
Non Palpable spleen
No Bowel sounds
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Reflexes
Plantars-flexor
Cerebral Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
INVESTIGATIONS
On 25th of August
