A 24 year old with fever

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.

This is a case of a 24 year old who came to the hospital with a chief complaint of fever and dry cough since one week

HISTORY OF PRESENTING ILLNESS

Patient has come with a chief complaint of fever since one week, sudden in onset and intermittent. Not associated with chills, body pains, nausea or vomitting, rashes

Patient also complained of dry cough with no sputum since one week

Patient also complained of decreased stools since the onset of fever.

Patient had a similar complaint one year ago. He was diagnosed with jaundice by the local practioner and that he had decreased RBCs. He had used ayurvedic medication and his symptoms were relieved in one month.

He developed jaundice again 6 months later and used ayurvedic medication again and his symptoms were relieved within one month.

Patient's attender commented on his pale appearance and yellowish discoloration of the eyes 6 months and one year ago

PAST HISTORY

Patients attender has told that he had delayed milestones and was mentally challenged since he was young.

He was the third son born from a consanguinous marriage and his two older brothers are normal according to the attender.

PERSONAL HISTORY

DIET: mixed but has always preferred to eat vegetarian food

APPETITE: normal

SLEEP: NORMAL

BOWEL and BLADDER: decreased

no habits

FAMILY HISTORY

Not relevant

GENERAL EXAMINATION:

Pt. is consicous , cooperative and oriented to time place person

Thin built , moderately nourished

Patient is C/C/C

VITALS

TEMP: afebrile

BP : 100/50

PR :76 BPM

RR: 20

Pallor present

Icterus present

No cyanosis, clubbing, lymphadenopathy

SYSTEMIC EXAMINATION

CVS - S1, S2 heard and no murmurs

RS - BAE + , No added sounds

P/A : Soft , No tender, no evidence of organomegaly.

CNS : No Focal neurological deficits.

INVESTIGATIONS

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BHARGAVI KANTIPUDI ROLL NO 21

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