General medicine case discussion

April 17 , 2023

 General medicine case discussion

E LOG MEDICINE CASE

17/04/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : Mamatha. N

Roll no : 65

2020 Batch

I''ve 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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission:08/04/2023

A 32 year old male farmer by occupation came to opd with 

Chief complaints : 

Fever since 9 days associated with cough for 3 days and chest pain. 

History of presenting illness :

The patient was asymptomatic 9 days back. Then he developed fever suddenly and the fever is intermittent with evening rise of temperature , associated with chills and headache ,throbbing type of pain at frontal lobe bilateral and not radiating. He took medication for fever but fever was not subsided and headache subsided on fever medication. 3 days back he developed dry cough with no sputum or pain.  Fever was associated with chest pain at right side of the trunk till abdomen.  

Past history :

No significant past history. 

Personal history :

Appetite : Normal 

Diet : Mixed diet 

Sleep : Inadequate due to fever 

Bowel and bladder movements : Regular 

Allergies : Absent 

Addictions: Kini daily and occasional alcohol consumption. 

Family history :

 No significant family history.