A 42 year old female came with complaints of cough, SOB, difficulty in swallowing
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.
CASE PRESENTATION
A 42 old female patient who is a tailor and labourer by occupation came to general medicine opd with cheif complaints of cough,shortness of breath and difficulty in swallowing and fever.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 month back and she had cough which is dry and not induced on medication. patient had fever 1 month back which is high grade and continuous and it lasted for 1week and then got reduced .Now again she had fever since 1day,high grade,continuous not associated with chills and rigors.
PAST HISTORY
Patient is not a k/c/o diabetes mellitus, hypertension, asthma, T.B, epilepsy and CAD
PERSONAL HISTORY
Diet -mixed
Appetite - decreased
Bladder and Bowel movement - regular
Sleep -normal
No known allergies
No history of addictions
Menstrual history-regular
FAMILY HISTORY
not relevant
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
Pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
Pedal edema absent
VITAL SIGNS-
Temperature: 101 F
Pulse: 139 /min
BP: 110/80mm of Hg
Respiratory rate: 26 cpm
SpO2: 96%
SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds -decreased
Dull note on percussion-left lower lung
ABDOMEN-
Abdomen is scaphoid.
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard
CENTRAL NERVOUS SYSTEM
Conscious
Speech- normal
Signs of meningeal irritation -
no neck stiffness
Cranial system - intact
Motor system - intact
Sensory system - intact
Cerebeilar signs
Finger nose- in coordination
Knee heel - in coordination
PROVISIONAL DIAGNOSIS
Dengue ,thrombocytopenia,pleural effusion.
INVESTIGATIONS
