General Medicine E - log by Kehkashan Tabassum [Roll no: 38]

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. CHIEF COMPAINT: A 62 year old male who is a farmer by occupation came to OPD with the chief complaint of: -shortness of breath since 3 months -cough with sputum since 3 days -fever occasionally (on&off) HOPI: Patient was apparently asymptomatic 1 year back, then he developed shortness of breath for which he was taken to private hospital and was Rx with nebulization and oxygen and was relieved. Patient was asymptomatic 6 weeks. Then he developed fever (on&off) associated with climate change. The SOB was insidious in onset, slowly progr

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed, informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. CHIEF COMPLAINT: A 70 year old female who is a housewife by occupation came to OPD with chief complaints of decreased appetite since 1 month HISTORY OF PRESENT ILLNESS: Patient was asymptomatic 1 month back, then she started to loose her appetite. Daily routine: She wakes up at 6:00 am and do the household chores and complete her breakfast. She eat chapatti for breakfast. And rice for lunch and dinner. Since one month she lost her appetite and didn't enjoy eating food. PAST HISTORY: K/C/O hypertension since 1 month on medication ta