This is an a 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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
Chief complaints;
H/o fever since 20days
H/o cough since 10 days
H/o cold since 10 days
Hopi:
Patient was apparently asymptomatic 20 days backlater developed fever, which was intermittent,more at night, associated with chills and rigor not relieved on medication . Fever low grade to high grade
Cough insidious onset associated with sputum, mucoid, non foul smelling,non blood stained, more at night relieved with medication
Cold since 10 days
Patient had h/o palpitations, burning micturition weekstream of urine
No H/o chest pain, vomiting, loose stools,
No H/o PND, orthopnea
No H/o headache
Past history:
HTN since 1 year on tab amlong 5 Mg PO/OD
N/K/C/O dm, TB, Asthma , Epilepsy , CVA, CAD, Thyroid disorders.
Personal history :-
Diet - Mixed
Appetite - normal
Bowel and bladder - regular
Sleep - adequate
addictions occasionally alcoholic
No H/o food and drug allergies
Family history:-
Not significant
General physical examination:
Patient Patient is conscious, coherent, cooperative ,moderately built and nourished
No signs of pallor ,icterus, cyanosis, clubbing, generalised lymphadenopathy, edema
Vitals at the time of admission
Temp- afebrile
BP-140/80mmHg
PR- 86 bpm
RR - 18 cpm
SpO2- 99 % at RA
Systemic examination:
Cardiovascular system:
Inspection-
Shape of chest-Normal
No precordial bulge.
No dialated veins,scars and discharging sinuses.
No visible pulsations.
Palpation-
Apical beat felt in 5th intercostal space.
No parasternal heave and thrills
Auscultation-
S1S2 heard
No murmurs heard
Respiratory system:
-Inspection:
Trachea -appears to be central
Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.
elliptical in shape.
No chest wall defects.
No scars and sinuses.
-Palpation:
All the inspectory findings are confirmed.
Trachea central in position
-Percussion Right Left
Supraclavicular R
R
Infraclavicular R R
Mammary R R
Inframammary R R
Axillary R R
Infraaxillary R R
Suprascapular R R
Infrascapular R R
R-Resonant
-Auscultation Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS. NVBS
Inframammary NVBS NVBS
Axillary NVBS NVBS
Infraaxillary Crepitations. Crepitations
Suprascapular NVBS NVBS
Infrascapular NVBS NVBS
(NVBS- Normal vesicular breath sounds)
Central Nervous system:
No focal neurological deficit
Investigations :
Provisional diagnosis:
Lower respiratory tract infection
Treatment:
Iv fluid NS @ 50ml/hr
Inj pcm 1 gm /sos
Inj ceftriaxone 2 GM iv/bd
Inj pan 40mg iv/od
Tab Azithromycin 500mg po/bd
Tab pcm 650mg po/tid
Tab montek ls po/hs
Tab grilinctus15ml po/tid
Nebulization with duolin 6th hourly
Inj neurobion iv/od
Grbs, pr, bp, rr, spo2 monitoring 4th hourly
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