General Medicine Case Discussion

April 26 , 2023

 General medicine case discussion

E LOG MEDICINE CASE

20/04/2023

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:22/04/2023

A 45 year old patient driver by occupation from narketpally came to causality with 

Chief complaints : 

Body shaking since four days associated with fever. 

History of presenting illness :

The patient was asymptomatic 4 days back. Then he developed fever associated with tremors. 

Fever was first observed in the morning which is continuous and not associated with chills, rigor, headache. 

Tremors are continuous. 

He had 3 episodes of vomiting after taking ORS which is non projectile, non bilious with food as contents. 

He went to RMP  where he had given 2 bottles of saline for fever. But fever didn't subsided. 

Past history :

Patient has a past history of jaundice 10 years back. 

Patient has a history of similar complaints 5 months back and diagnosed with slight hepatomegaly. 

No history of previous surgeries. 

No history of DM,  TB, HTN, epilepsy, coronary artery disease. 

Personal history :

Appetite -Decreased slightly ( no significant weight loss). 

Sleep - Inadequate 

Diet - Mixed 

Bowel and bladder movements - Regular 

Allergies - None 

Addictions - Alcohol consumption since 25 years , 90 ml per day. 

Smoking since 20 years , one packet per day. 

Family history :

His mother is a known case of hypertension. 

General examination :

Conscious 

Coherent 

Cooperative 

Moderately built 

Moderately nourished 

Pallor : Absent

Icterus : Absent 

Clubbing of fingers : Absent 

Cyanosis : Absent 

Lymphadenopathy : Absent 

Pedal edema : Absent