A 55 YEAR OLD PATIENT WITH FEVER CHEST PAIN AND LOSS OF APPETITE
A 55 years old patient presented with fever, chest pain and loss of appetite
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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 inputs on the comment box"
-History of present illness:-
- Past history:-
- Personal history:
-Diet - mixed
-Appetite is normal
-Bowel and bladder - normal and regular
-No Known allergies
- Family history:-
- Temperature- febrile
- Respiratory rate - 28 cpm
- Pulse rate - 62 bpm
- BP - 120/80 mm Hg.
- Spo2 at room air is 96%
- GRBS - 102 mg/dl
—>SYSTEMIC EXAMINATION:-
-CVS : S1 S2 heard, no murmurs
-Respiratory system : normal vesicular breath sounds heard(vesicular)
—>Abdominal examination:-
INSPECTION : -
-Shape of abdomen- scaphoid
-No tenderness of abdomen
- Umblicus - normal
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny
—PALPATION :-
No Local rise of temperature
Tenderness absent
Guarding present
Rigidity absent
hernial orifices normal
Fluid thrill absent
Liver not palpable .
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
—> RESPIRATORY EXAMINATION:—
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
—>PROVISIONAL DIAGNOSIS:-
—>INVESTIGATION:-
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