A 57 YEAR OLD PATIENT WITH FEVER AND BURNING MICTURITION
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through a series of inputs from an 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-related online learning portfolio and your valuable inputs on the comment box.
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 to come up with a diagnosis and a treatment plan.
CHIEF COMPLAINTS:
Fever since 10 days
Burning micturition since 8 - 9 days
Decreased appetite since 4 days
Generalised weakness since 4 days
Vomiting since 2 days
HOPI:
Patient was apparently asymptomatic 10 days ago, then she developed fever which was of intermittent type, associated with chills, which was followed by burning micturition from the next day. She had 2 episodes of vomiting, which is non-bilious, non-projectile, with water as its contents. There is a h/o decreased appetite and generalised weakness since 4 days.
Regurgitation of food +
Retrosternal burning sensation +
No h/o abdominal pain, loose stools, and constipation
No h/o hematuria, frothy urine
No h/o loss of weight
PAST HISTORY:
No similar complaints in the past
No previous surgeries
Not a known case of diabetes, hypertension, tuberculosis, asthma, CAD, epilepsy
PERSONAL HISTORY:
Appetite: decreased since 4 days
Diet: mixed
Bowel movements: regular
Bladder: burning micturition since 8 - 9 days
Sleep: adequate
Addictions: none
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
The patient is conscious, coherent and cooperative, moderately built and nourished, and is well oriented to time, place and person.
The patient was examined in a well-lit room after her consent was taken.
Pallor: absent
Clubbing: absent
Lymphadenopathy: absent
Cyanosis: absent
Pedal edema: absent
Tongue: dry
VITALS:
Patient is febrile on touch, temperature: 101.9 °F
Blood pressure: 130/100 mm Hg
Pulse rate: 110 bpm
Respiratory rate: 16 cpm
SpO2: 98% on RA
GRBS: 112 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1, S2 heard; no murmurs
RS: bilateral air entry present; normal vesicular breath sounds heard in all areas
Per abdomen: soft; mild tenderness noted in the right hypochondriac and epigastric regions
INVESTIGATIONS:
CHEST X-RAY:
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