General Medicine - 9

14 November, 2022

A 45 YEAR OLD MALE CAME WITH COMPLAINTS OF FEVER ASSOCIATED WITH HEADACHE.

Hi, I am Dussa Sri Snehitha, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:

A 45 year old male, daily labourer by occupation, came with chief complaints of:
- fever associated with headache since 6 days
- nausea and vomiting since 1 day

History of present illness:

The patient was apparently asymptomatic 6 days back. Then he developed high grade fever associated with chills and rigors which was relieved on medication.

He also gave history of headache which was on and off since 4 days.

He had a history of arthralgia since 4 days with generalised weakness.

He was admitted now for further management and treatment.

Past history:

- known case of hypertension

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: alcohol occasionally
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema

VITALS:

Temperature: 98.4 F

Pulse: 69 beats per minute

Respiratory rate: 19 cycles per minute

Blood pressure: 130/80 mm of Hg

SPO2: 98%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

No tenderness
No palpable mass
palpable liver - hepatomegaly
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

INVESTIGATIONS:
ECG:
PROVISIONAL DIAGNOSIS:
Viral pyrexia.

Comments

Post a Comment

Popular posts from this blog

General Medicine -17

A 22 YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF FEVER, COUGH AND RUNNING NOSE. This is an online E log book by D.Sri Snehitha and Ebrahim Badshah 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-centred online learning portfolio and your valuable comments 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.  CHIEF COMPLAINTS: A 22 year old male student came with the...
Read more

General Medicine - 19

Image
A 70 YEAR OLD MALE CAME TO OPD WITH BILATERAL PEDAL EDEMA This is an online E log book by D.SRI SNEHITHA 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-centred online learning portfolio and your valuable comments 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.  CHIEF COMPLAINTS: A 70 year old male came with the chief complaints of:  - swelling of both feet since...
Read more

General Medicine -14

Image
A 26 YEAR OLD FEMALE CAME WITH SHORTNESS OF BREATH AND CHEST PAIN. 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-centred online learning portfolio and your valuable comments 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.  CASE SHEET: Chief complaints: A 26 year old female, hailing from nakerekal, agricultural worker by oc...
Read more