A 60 years old female came to casualty with the complements the fever since 15 days, Nausea, Vomiting

19/7/23

22/7/23

A 60 years old female patient came to casualty with the complaints of fever since 15 days, Nausea, vomiting.

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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 upon with diagnosis and treatment plan. 

Chief complaints:

Fever since 15 days

Nausea and vomiting.

History of presenting illness : 

The patient was apparently asymptomatic since 15 days ago she then developed  low grade intermittent fever not associated without chills and rigors,relieved on medication.

Cough expectation mucoid sputum not blood type. Complaint of Nausea and vomiting since 15 days and 2-3 episodes daily. Watery,not projectile, Not blood type, food particles comesout. History of constipation and decreased appetite since 15 days.                       No c/o loose stools, burning micturation and abdominal pain . No bipedal edema ,No puffiness of face, No palpitations ,No SOB, Decreased urine output 

Past history: 

 

C/O  pain in back while coughing.

Not a known case of  Diabetes mellitus, Hypertension, Tuberculosis, Epilepsy , Thyroid problems, Bronchial asthma ,CVA,CAD. 

History of NASID's abuse.

Personal history :

   

Mixed diet,

Adequate sleep,

Reduced appetite, 

Normal bladder movements,

Irregular bowel habits.

No history of smoking and chewing of tobacco.

No history of alcohol consumption. 

Family history: 

        

No significant family history. 

General examination :

 

No pallor .

No icterus.

No clubbing.

No cyanosis.

No  generalized lymphadenopathy and bipedal edema.

Vitals : 

Temperature: 98.9°f

Pulse rate.     :  112 / min

Respiration rate :  16 /min

BP.                   :   100 / 70 mm/Hg .

SYSTEMIC EXAMINATION:

RS: Bilateral chest air entry, 

CVS: S1,S2 positive

PA: soft, no tenderness

CNS : Hmf+intact

INVESTIGATIONS:

Diagnosis  :                                                     

Pyrexia decreased evaluation.