79Y/F WITH SOB AND FEVER

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 

- SOB since 5 days associated with cough w/o expectoration

- Fever since 2 months 

HISTORY OF PRESENTING ILLNESS

the patient was apparently alright 1 month ago then she started developing fever which was low grade, intermittent, not associated with chills and rigors, relieved on taking medication associated with generalized weakness. 

She also started developing SOB since 5 days grade III-IV which was aggravated on exertion, reduced a little on taking rest, this was associated with cough with scanty sputum, non blood tinged, whitish in color, non foul smelling. 

No orthopnea, pnd 

No pedal edema 

Not a known case of DM, Hypertension, epilepsy, cad, cva

Known case of Asthma since 30 years using Fometrol and Budesonide 

General examination 

The patient is conscious, coherent, cooperative

Well oriented to time, place and person

Moderately built and nourished 

Pallor present 

No signs of icterus, cyanosis, clubbing, edema, lymphadenopathy 

Vitals:

Bp: 

Pr: 

Systemic examination

CVS: S1, S2 heard, no murmurs 

RS: BAE +ve, Rhonchi heard in all quadrants 

CNS: No focal neurological deficits 

P/A: Soft, non tender, bowel sounds heard 

Provisional diagnosis: