THEJASWI JELLA ROLL NO 59

 This is 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 patients 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 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.   CONSENT AND DE-IDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers sha

 Patient came to the opd with chief complaints of left sided chest pain and sob since 1 year HOPI: Patient was apparently asymptomatic 1 year back then she developed left sided chest pain which is non radiating. C/o sob grade II since 1 year .Which was insidious in onset and gradually progressive. Increases on lifting heavy weights( >/= 5 kg) and on supine position and  Associated with palpitations. No H/o orthopnea, PND, weight gain No C/O fever, vomitings , loose stools, burning micturition, cough. Daily routine: Patient used to wake up at 5 AM and drinks tea at 7 AM And have breakfast at 8 AM (rice) After having breakfast, she goes  to work at the construction site as a daily labour and eats her lunch at 1 PM (rice) Then after eating rice, she gets back to her work  She leaves the construction site at 5 PM. And goes back to home and have tea at 5:30 PM. And have her dinner at 8 PM  And goes back to sleep at 9 PM  Patient started to feel shortness of breath one year back. Then dec

 Chief complaints:   Patient came with cheif complaints of burning type of sensation of whole body since 1 week. Fever since 1 day HOPI:  Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia). He also have complaints of fever since today afternoon associated with chills , relieved on medication. H/o of  burning micturition since 4-5 days  No H/o decreased sensations No h/o bowel and bladder incontinence. No h/o seizure activity No H/O cold, cough, sore throat No H/o nausea , vomiting, pain abdomen No H/o loose stools PAST HISTORY: Not a k/c/o dmII, htn, thyroid disorders,asthma,epilepsy GENERAL EXAMINATION: Patient is conscious, coherent No pallor, icterus, cyanosis, clubbing, lympha