57 YR male with Fever since 1 month

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered 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 up with diagnosis and treatment plan.


CHIEF COMPLAINTS:

Fever since one month 


HOPI :

Patient was apparently asymptomatic one month back then he developed fever, which is insidious in onset, high-grade, intermittent associated with chills and rigors.Generalised body pains were present.

H/o small swellings since 10 days over bilateral lower limbs and right hand, which is associated with pain and pus point was present.

H/o headache, diffuse type, not associated with photophobia,phonophobia,blurring of vision,Watering of ice.

H/o vomiting since one day associated with nausea, non-projectile, non-bilious non-bloodstained containing food particles as content .

H/o cough since 1 day,dry cough.

No history of abdominal pain, loose stools, constipation.



PAST HISTORY:

K/C/O T2DM , HTN Since 10 years

N/K/C/O Epilesy, Asthma, Thyroid disorders,TB.


PERSONAL HISTORY:

He is a Handloom worker.He wakes up at 5 in the morning,gather things for making sarees and He does his breakfast at 8:00AM . He works till 7 PM .He has his food at 1 PM in afternoon and 8 :00 PM at night , sleeps at 9 PM


DIET :mixed

APPETITE :decreased 

SLEEP: adequate 

BOWEL AND BLADDER :Regular 

H/O Alcohol intake Since 20 Yrs every day about 50 to 100 ml

Stopped since 3 months.

No H/O Tobacco intake

No H/O Allergies


FAMILY HISTORY: 

N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders.

CLINICAL IMAGES:










GENERAL EXAMINATION:

Patient is conscious,coherent and co operative.

Well oriented to time,place and person

No Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema.

VITALS:

TEMP: 104.1F

BP: 110/80 MM/HG

PR: 94 BPM

SPO2: 98% at RA

RR: 18CPM


SYSTEMIC EXAMINATION:

CVS : S1 , S2 heard, no murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits

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