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A 24 year old with fever

This is an 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.



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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