med opd case 1


November 02, 2023

A 22 YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF FEVER, COUGH AND RUNNING NOSE.

This is an online E log book by D.Sri Snehitha and Ebrahim Badshah 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-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS:

A 22 year old male student came with the chief complaints of:
- fever, cough, running nose since 2 days

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 2 days back. He then complained of throat pain, fever, insidious in onset, intermittent in nature, cough associated with sputum, running nose since 2 days.
He also complained of weakness and fatigue.
No aggrevating and relieving factors.
No history of vomiting,diarrhea, constipation
No history of night sweats and chills and rigors.
No history of headache
No history of burning micturition

PAST HISTORY:
  Previous history of asthma 6 years back and relieved with medication, no attacks later.

Not a known case of Diabetes mellitus, hypertension, tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.
No similar complaints in the past
No previous surgical history

PERSONAL HISTORY:


Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: decreased
Habits: nil
No history of allergy.

Family history:
Insignificant

Drug history: Paracetamol 650mg TID since 2days


GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration

VITALS:

Temperature: febrile

Pulse: 78 beats per minute, irregular

Respiratory rate: 18 cycles per minute

Blood pressure: 110/70 mm of Hg

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