33 yr Old male with sob ,fever,cough

September 20, 2022

33 yr Old male with sob ,fever,cough

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from 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 centered online learning portfolio and your valuable comments in comment box are most welcomed

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

A 33 year old male came to the casualty around 10 pm with

Chief complaints of sob since 3 days.

Fever since 10 days

Cough since 10 days

Chest pain since 10 days

Pain abdomen since 10 days

HOPI :

Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. Then patient got tested positive for Widal after 4 days of onset of fever. He used symptomatic medication for a week. Then, he developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed from grade 2 to grade 4 ,SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days

Past History :

Admitted to a hospital for pain abdomen for 4 days

Not a k/c/o HTN, DM, CAD, ASTHMA, EPILEPSY, THYROID DISEASE.

Personal history:

Constipation since 4 days

Appetite : decreased

Sleep : disturbed

Chronic alcoholic since 10 years, alcohol consumption increased since past 6 months. Consumes half bottle of whiskey daily since past 6 months. Last consumed 10 days back.

Family History : No significant family history.

On examination:

Moderately built and moderately nourished.

Vitals at the time of admission

BP - 100/80 mm Hg

SpO2 - 22 , on 15 lit of O2 - 71

RR - 66 cpm

PR - 127

Temp - 99 F, 103 F @ 10:45 pm