E log of 32 year old male

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered 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 up with diagnosis and treatment plan.

A 32 year old male who is a village revenue assistant by occupation came to opd with c/o 

Fever since 10 days

Productive cough since 5 days

HOPI:

Patient was apparently asymptomatic 10 days ago then he developed fever which is low grade , intermittent type, Mainly during night time and relived temporarily with medication , associated with chills and rigors.

C/o productive cough with mucoid sputum, intermittent type, which is mainly during night time.

-Generalised weakness present

-Not associated with burning micturition ,cold,rash ,body pains ,vomitings,loose stools

-Associated with sob on doing ordinary activity( grade 2 mmrc) since 5 days , relieves on taking rest

Past history:

Not a k/c/o DM,HTN ,CVA,CAD ,ASTHMA

Patient had a trauma history 5 years back his leg was injured totally, bandage applied for it

He is know case of HIV (diagnosed 1 year ago )and he is on medication

Personal history :

Diet-mixed

Appetite-normal

Sleep-adequate

B and bladder movements-normal

Addictions-toddy -12 years back ,occasionally

Daily routine -

The patient is a village revenue assistant by occupation.He wakes up by 7 am freshens up and takes his breakfast at 8:00am and goes to his work,Then he takes lunch break at 1pm and goes back to work ,he takes dinner by 8 pm and sits with his children for some time the goes to sleep at 9pm.

His daily activities are disturbed. Due to his symptoms

GENERAL EXAMINATION:

-No palor

-No Icterus

-No cyanosis 

-No lymphadenopathy

-No edema

-No clubbing of fingers

Temperature:

 Febrile - 99.9°F

Pulse: 82 beats per minute

Respiratory rate: —16 cycles per minute

Blood pressure: 130/90 mm of Hg

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills

No murumurs

Cardiac sounds: S1, S2 present 

Respiratory system:

Bilateral airway entry present ,crepts heard in IAA ,left ISA ,Right IAA

Abdomen: 

shape scaphoid 

umbilicus central , inverted

no increase in local temp,no tenderness

No spleenomegaly

No hepatomegaly

BS+

Investigations:

Diagnosis:

Pyrexia under evaluation

?pulmonary Tb

? community acquired pneumonia