This is an E log book to discuss our patients de identified health data shared after guardians informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS
- Fever since 1 day
- Vomiting since 1 day
- SOB ( grade III initially)
HISTORY OF PRESENTING ILLNESS
The patient was apparently alright 1 day ago when she had developed sudden fever insidious in onset, gradually progressive, high grade, not relieved on medication, continuous, associated with chills. She had just come home from her work and took her afternoon nap as per usual when this started. She also developed 2 episodes of vomiting, non projectile water as content. She also developed SOB grade III (MMRC) initially when she walked till the bathroom which was very near and developed SOB and later progressed to grade IV (MMRC). She had not slept all night and she started defecating and urinating in her clothes. In the morning they took her to an RMP who suggested they bring the patient here.
PAST HISTORY
H/O similar complaints in the past almost 9 months ago when the com
FAMILY HISTORY
No similar complaints in the family
PERSONAL HISTORY
DIET: Mixed
APPETITE: decreased
SLEEP: adequate
B&B: Regular
He consumes alcohol socially
No allergies
GENERAL EXAMINATION
The patient was conscious, coherent, cooperative, well oriented to time, place, person. He was moderately built and moderately nourished.
Comments
Post a Comment