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85 year old male

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85 year old male came to casualty with chief complaints of weakness of left upperlimb and lowerlimb since 15 days Difficulty in swallowing since 15 days  Deviation of mouth towards left side since 15 days No h/o of involuntary micturation No history of involuntary defecation K/C/O HTN and on medication On examination : Patient conscious , coherant , cooperative  Past history : Hypertensive and on medication No relevant family and personal history Temperature : afebrile Pulse rate: 100/ min Blood pressure : 140/90 mmhg Respiratory rate : 22 cycles per min SPO2 :99 % at room air GRBS: 198 mg/dl CVS : S1 and S2 heard  Respiratory system : NVBS present , BAE present CNS : Conscious  speech - normal no signs of meningeal irritation Tone :Increased  in left side power:      Right.         left                     4+/5.        4+/5 Reflexes :                        Right.              left Biceps:.         +.                     +++ Triceps:.        +.                      +++ Gait          S
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32 year old male

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Patient was apparently asymptomatic 1 day ago.32 year old male lorry driver by occupation came to casualty with chief complaints of pain in abdomen since one day. Patient had alcohol intake today morning (14/09/21), and had food in the afternoon.  Then he developed pain in abdomen at umbilical region, throbbing type, non radiating, aggravated after food intake, not associated with nausea, vomiting , constipation and loose stools, No History of fever and burning micturition. Not a known case of hypertension diabetes epilepsy tuberculosis asthma. O/E: vitals: temperature AFEBRILE, pulse rate 88 BPM, respiratory rate 16 CPM , BP 130/80 mm Hg, spo2 98% at Room air. CVS : S1 S2 heard RS: BAE+ NVBS + PA: obese abdomen, tenderness in gastric and hypochondrial region, bowel sounds present. Provisional diagnosis: Acute pancreatitis? Secondary to alcohol dependence INVESTIGATIONS :  HEMOGRAM : HB : 14.3 GM/ DL TLC : 11,400 CELLS/ CUMM RBC : 4.34 MILLION/ CUMM PCF : 2.05 PCV : 40.1 VOL %
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75 year old male

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A 75 year old male patient came to casualty with the complaints of fever  and cough since four days  Patient was apparently asymptomatic one week ago. Then , he developed pain abdomen ( generalised ) since 1 week , not associated with vomitings and difficulty in passing stools. He developed fever since 4 days which was high grade associated with chills and cough since 4 days associated with expectoration. H/O orthopnea present , H/O dribbling of urine . No H/O pedal edema, PND K/C/O DM and on OHAs  K/C/O HTN He is a known alcoholic and last intake was 15 days back. General examination: The patient is conscious coherent and cooperative Moderately built and moderately nourished.  Vitals: Temp: afebrile, PR 120bpm, RR 22 cpm, BP 110/60mm Hg , GRBS 208 mg% P/A:  Shape of abdomen: scaphoid Non tender Liver and spleen - not palpable Bowel sounds are present CVS: S1, S2 + RS: BAE + , NVBS + CNS: NFND Investigations: 8 /9 /10
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45 year old female

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45  female came to opd with chief complaints of fever since  15 days  which is low grade , intermittent and decreased on medication associated with dry cough , body pains  and generalized weakness since 10 days  h/o loose stools 4 to 5 episodes 4 days back which decreased on medication  no h/o pain abdomen , vomiting ,and burning micturation  no h/o cold / sob/ headache / rash and other complaints  h/o diabetes since 10 years and on OHA no h / o hypertension , CAD, asthma , Tuberculosis personal history: Appetite : lost bowel and bladder movements regular  no other addictions Family history : no relevent family history   General examination: No pallor , Icterus, cyanosis, clubbing and lymphadenopathy Temperature : 98.6 F PR: 84 bpm RR: 18 Cycles per min Spo2 : 98 % at RA CVS:  S 1 and S 2  heard  Per abdomen : no tenderness present  Respiratory system:  BAE + and NVBS + CNS :  Intact  Diagnosis:  Viral pyrexia  under evaluation    Treatment given : Day 1 1. IVF - NS ,RL @ 45ml/hr 2. TA
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56 year old male

A 56yr old male came to casuality with  chief  complaints of  pain abdomen since 5 days polyuria since 5 days  Dyspepsia since 2 days  History of present illness:  patient was apparently asymptomatic 5 days back,then he developed pain in the abdomen (Epigastric region) non radiating,not associated with nausea,vomitings(burning type of pain) decreased on using medication  H/o alcohol binge 5 days back,then developed pain abdomen ( diffuse type, squeezinf type of pain) not associated with nausea,vomitings)  went to a local RMP and diagonsed with Diabetes mellitus (DE NOVO) and was started on (T.GLIBENCLAMIDE and METFORMIN)/PO/OD No H/O burning micturition,fever,cough,cold,SOB,tingling sensation of B/L UL and LL,loose stools and chest pain Past History : H/O simliar complaints in the past diagnosed as pancreatitis  not a K/c/o DM,HTN  k/c/o Alcoholic since 30 yrs  last intake (3-5 days back) he is a smoker ( stopped 8 years back ) Personal history: mixed diet normal appetite bowel regular
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1601006086 short case

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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 on inputs 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.  34 y/m labourer by occupation came with a chief complaints of fever since 10 days  cough since 7 days  sob since 4 days History of present illness: Pt was apparently asymptomatic 1 month back then develped SOB which is gr 2 and generalised weakness which is a/w fever (low grade,non continous ,not a/w chills an
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