This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed
I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
K. Tejarshini (Intern)
A 46 year old male came to opd with complaints of,
Fever on and off episodes:12 days
Loss of appetite:12 days
Pedal edema:7 days
Shortness of breath :7 days
Jaundice:7 days
Patient was apparently asymptomatic 12 days back then he complained of fever which is low grade, intermittent, on and off episodes get relieved on medication.
Patient complained of B/L pedal edema(grade 2)present below the knees, pitting type, present since 7days which get aggravated on standing for long periods and slightly reduced on taking rest.
Shortness of breath present since 7 days which is grade 2(developing shortness of breath while walking to washroom).
Patient also complained of loss of appetite :12 days
Patient also complained of abdominal tightness, bloatimg of abdomen.
No History of chest pain, chest tightness, palpitations.
No History of abdominal pain, vomitings, constipation, loose stools.
No History of burning micturition, decresaed urine output.
No bowel and bladder irregularities.
No Head ache, Giddiness, Confusion.
PAST HISTORY:
Known case of HTN since 3 years and medication.
Not a K/C/O DM, Asthma, TB, Epilepsy, CAD, CVA.
PERSONAL HISTORY:
Appetite:Normal(Decreased since 12 days)
Diet:Mixed
Bowel and Bladder habits:Regular
Addictions:
Consumes Alcohol since 25 years regularly (daily Quarter)
Tobacco chewing since 5 years.
GENERAL EXAMINATION:
Conscious, Coherent, Co-operative
Pallor-Present
Icterus-Present
Cyanosis-Absent
Clubbing-Absent
Lymphadenopathy:Absent
Pedal edema- B/L Pedal edema present upto knees
Raised JVP
Vitals:
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