GENERAL MEDICINE- Blog4

A women presents with fever chills , headache.

Hi I’m Mucha Sainath Reddy 3rd Semester Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 portfolio and your valuable inputs on the comment box is welcome.”

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 come up with a diagnosis and treatment plan. CHEIF COMPLAINTS:

•SOB Since 5 days (12/8/22)   

•Fever with chills , headache , general body pains since 8 days (8/8/22) 

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic then she developed fever on 9/8/22 for which she went to a local hospital diagnosed as TYPHOID and UTI 

HISTORY OF PAST ILLNESS: 

H/O MASTECTOMY  left ( 1 year back ) 

H/O RENAL CALCULI (1 year back ) 

N/k/c/o HTN DM THYROID CAD TB EPILEPSY

PERSONAL  HISTORY: 

 Occupation : house wife 

Appetite : normal 

Diet : mixed 

Bowel : regular 

Micturation : Normal 

No allergies 

Addictions : Alcohol ( teetotaler ) 

FAMILY HISTORY: 

NIL SIGNIFICANT 

TREATMENT HISTORY : 

Blood transfusions 

Surgery - mastectomy 

GENERAL EXAMINATION: 

PALLOR : PRESENT 

Clubbing , cyanosis , icterus, edema, lymphadenopathy: ABSENT 

VITALS : 

TEMP : 102 F 

PULSE : 116 

BP : 100/70 

SPO2 : 98 

GRBS : 110

RESPIRATORY RATE : 26 CPM 

SYSTEMIC EXAMINATION: 

CVS : No thrills , no murmurs, S1 S2 present 

RESPIRATORY: No dyspnea, no wheezing , breath sounds - vesicular, trachea - central position 

BAE +

SOB (Grade 3 ) 

Pain in 4th intercostal space 

ABDONEN : scaphoid shape , bowel sounds present , free fluid absent , liver and spleen non palpable 

CNS : pt is conscious, coherent , speech normal , all reflexes present 

 

INVESTIGATIONS : 

PAST INVESTIGATION REPORTS:

HISTOPATHOLOGY REPORT 

PROVISIONAL DIAGNOSIS: 

TYPHOID 

TREATMENT: