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.
Chief complaints:
Fever since 7 days
Pain abdomen since 7 days
Burning micturition since 3 days
History of present illness:
Patient was apparently alright 7 days back then he had fever which is sudden in onset,high grade and with chills and rigors, releived by taking medication.pain abdomen since 7 days in right hypochondriac,right lumbar, umbilical region,needle pricking type of pain , aggrevated during inspiration
H/o burning micturition since 3 days,no urgency , frequency, hesitancy.
No chest pain,sob, palpitations
No nausea, vomiting
No loose stools
No increased or decreased output
Past history
Not k/c/o HTN,DM,TB, EPILEPSY,CVA
Family history:- not significant
Personal history:
Appetite:- normal
Diet:- mixed
Sleep :- adequate
B& B :- regular
No addictions
General examination:-
Patient is conscious, coherent, cooperative well oriented to time place and person .
Moderately built, moderately nourished
Pallor:- absent
Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Generalized lymphadenopathy:- absent
Bilateral pedal edema :- absent
Vitals:-
Bp:120/80 mmhg
Pulse rate:-80 bpm
RR:- 18 cycles per min
Temp :-
Systemic examination:-
Cvs :- s1,s2 heard no murmurs
Cns :- no focal neurological deficits
Abdomen :- soft ,non tender
Rs: decreased air entry right side,no crepts,wheeze
Investigations:-
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