A 60 year old woman with fever, cold cough and headache
Hi, I am Shivraj Sontakke, 5th 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 patients 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 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
A 60 yrs woman who is the residence of suryapet came to the general medicine OPD with the chief compliance of headache since 1 month, fever since 1 month,cold since 15 days, cough since 10 days
History of present illness :
The 60 yrs patients is asymptomatic before 1 month then the patient developed headache localised at parital region radiating to nack and spine accompanied with fever and relieved with medication.
Fever, which is continuous, High grade present all over the day, non progressive and associated with chills and rigor. Cold since 15 days, no nasal obstruction
The cough started 10 days back which is productive cough with thick white sputum and aggrivated evening time and cold climate condition and relieved by medication
No complaints of chest pain shortness of breath orthopnea, PND
No complaints of sweating and palpitations
No complaints of loose stools nausea and vomiting
No complaints of burning micturition
History of past illness :
The patient is not a known case of DM, hypertension, asthma, epilepsy and allergy
Family history :
Their is no significant family history.
Personal history :
The patient is taking mixed diet , loss of appetite (1 month back) , regular bowal , taking adequate sleep.
The patient is not addicted to alcohol and smoking
Physical examination :
1) General examination :
The patient is concious, coherent cooperative moderately built
No pallor, ictures and cyanosis, lymphadenopathy clubbing of fingers and oedma.
Vitals :
1) Temperature: 96 F
2) Pulse Rate : 88
3) Respiratory rate : 20
4) Blood pressure : 130/70 mm of Hg
Systemic Examination :
1) CVS :
Sound: S1and S2 present
No aortic and mitreal regulation
2) Respiratory system examination
Position of trachea: Central
Weeze : absent
Dyspnea : absent
Breathing Sounds: vesicular
3) gastrointestinal system examination
Shape of abdomen: Normal
Tenderness : absent
Palpable mass: absent
Palpable live : absent
Palpable spleen : absent
Investigation :
Provisional diagnosis
Pyrexia decease evaluation
Treatment :
1) IV Fluid NS @ 75 ml/ hr
2) INJ Neomol 1 Gm IV / sos
If temp greater than 101F
3) Tab Paracetamol 650 mg
4)Tab levocetrizine
5)Syp Ascoryl
