52 year old male with chief complaints of fever, vomiting and generalized weakness.
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 diagnosis with a treatment plan.
This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.
A 52 year old male, farmer by occupation, resident of Chityala, presented to the OPD with chief complaints of fever and vomitings since 1 month.
History of present illness:
The patient was apparently asymptomatic 1 month back, then he developed low-grade fever, intermittent not associated with chills and rigors .
He has history of decreased digestion and vomitings after taking food, 2 episodes/day which is non projectile, non bilious and with food as contents.
He also has history of bilateral loin pain and lower back ache since 1 month which is non radiating and continuous.
The patient also complains of 5kg weight loss in the past 1 month.
The patient also complains of generalised weakness and indigestion since 20 days.
There is history of dark coloured stools 3 days back.
No history of pain abdomen.
The patient got a blood transfusion ( PRBC ) on 30/10/22 . He got another blood transfusion on 31/10/22 . His initial hemoglobin level was 4.9 mg/dl, after the transfusions it has now raised to 7 mg/dl. He did not have any reactions during or after the transfusions.
Blood group O positive.
Past history : No H/O HTN, DM, epilepsy, TB, thyroid disorders, coronary artery disease, asthma.
Personal history : 1 month back when the patient was alright, he used to do cotton farming from morning to evening. But now as he is ill since 1 month, he stopped farming and is now staying back at home along with his mother .
Diet ‐ mixed
Appetite ‐ decreased
Sleep ‐ decreased
Bowel and Bladder movements ‐ decreased
Addictions ‐ was an alcoholic but stopped 1 month back
General Examination : The patient is conscious, coherent but non cooperative, poorly built and nourished.
Pallor is present.
Icterus, cyanosis, clubbing, pedal edema are absent.
Generalised lymphadenopathy is absent but left supraclavicular lymphadenopathy is present.
Right Left
VITALS :
31/10/22 :
Temperature - 98.6F
BP - 120/70 mm Hg
HR - 86 bpm
RR - 18 cpm
Systemic examination:
Not examined as the patient was non cooperative.
Investigations:
Hemogram
Endoscopy done on 1-11-2022.
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