Case1

  I am R yaswanth  Reddy  , 3rd Sem Medical Student.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 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 -Itching all over skin since 4 years - SOB during cold climates  Addiction Alcoholic since 15 years stopped 6

  CHEIF COMPLAINTS: •SOB Since 5 days (12/8/22)     •Fever with chills , headache , general body pains since 8 days (8/8/22)  HISTORY OF PRESENT ILLNESS :  Patient was apparently asymptomatic then she developed fever on 9/8/22 for which she went to a local hospital diagnosed as TYPHOID and UTI  HISTORY OF PAST ILLNESS:  H/O MASTECTOMY  left ( 1 year back )  H/O RENAL CALCULI (1 year back )  N/k/c/o HTN DM THYROID CAD TB EPILEPSY PERSONAL  HISTORY:    Occupation : house wife  Appetite : normal  Diet : mixed  Bowel : regular  Micturation : Normal  No allergies  Addictions : Alcohol ( teetotaler )  FAMILY HISTORY:  NIL SIGNIFICANT  TREATMENT HISTORY :  Blood transfusions  Surgery - mastectomy  GENERAL EXAMINATION:  PALLOR : PRESENT  Clubbing , cyanosis , icterus, edema, lymphadenopathy: ABSENT  VITALS :  TEMP : 102 F  PULSE : 116  BP : 100/70  SPO2 : 98  GRBS : 110 RESPIRATORY RATE : 26 CPM  SYSTEMIC EXAMINATION:  CVS : No thrills , no murmurs, S1 S2 present  RESPIRATORY: No dyspnea, no w