A 60 years old female came to casualty with complaints of fever , nausea and vomitings.
July19,2023
July 22, 2023
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.
This E blog also reflects my patient cantered 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 upon with diagnosis and treatment plan.
This is a case of 60 years old female came to casualty with the complaints of fever since 15 days , Nausea and vomitings.
CHIEF COMPLAINTS :
Fever since 15 days
Nausea and vomitings.
HISTORY OF PRESENTING ILLNESS :
- Patient was apparently asymptomatic since 15 days ago she then developed fever .
- Nausea and vomitings since 15 days
- cough associated with discharge of white sputum since 3 days
- pain in left flank while coughing
- weakness of both hands and legs since 3 years .
PAST HISTORY :
N/K/C/O Diabetes mellitus, Hypertension, Tuberculosis, Epilepsy , Thyroid disorders.
PERSONAL HISTORY :
- Mixed diet
- Adequate sleep
- Reduced appetite
-Normal bladder movements
- Irregular bowel habits
- No history of smoking and chewing of tobacco.
- No history of alcohol consumption.
FAMILY HISTORY :
No significant family history.
GENERAL EXAMINATION :
Prior consent was taken and patient was examined in a well lit room.
Patient was conscious, coherent and cooperative.
- Pallor present
- No icterus
- No clubbing
- No cyanosis
- No generalized lymphadenopathy and bipedal edema.
Temperature: 98.9°F
BP - 100/70 mmHg
PR- 112 bpm
RR- 16 cpm
Spo2-98%
SYSTEMIC EXAMINATION :
RS: Bilateral symmetrical chest movement and air entry
CVS: S1,S2 heard
No murmurs
PA: soft, no tenderness and distension
CNS : Hmf+intact
Sensory and motor system normal
INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
Pyrexia decreased evaluation.
