general medicine postings case 3
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 diagnosis and treatment plan Ch.preethi Admission number:176050 27 year old men came to causality on 24/01/23 with C/O FEVER SINCE 1 WEEK HOPI: PATIENT WAS APPARENTLY NORMAL 1 WEEK BACK.HE THEN HAD FEVER WHICH WAS HIGH GRADE, INTERMITTENT WITH EVENING RISE OF TEMPERATURE AND NO CHILLS AND RIGORS AND IS RELIEVED BY MEDICATION.FEVER RELIEVED NOW. H/O COLD AND COUGH WITH EXPECTORATION-WHITE MUCOID SPUTUM,NOT BLOOD TINGED. H/O PAIN ABDOMEN TO RIGHT SIDE OF ABDOMEN. H/O VOMITINGS 3 DAYS BACK-4 EPISODES AND RELIEVED BY MEDICATION. H/O PASSING BLACK STOOLS SINCE YESTERDAY. HISTORY OF PAST ILLNESS: NO SIMILAR COMPLAINTS IN THE PAST NOT A K/C/O DM/HTN/TB/ASTHMA/EPILESPY/CVA/CAD. PERSONAL HISTORY: DIET:MIXED APPETITE:NORMAL BOWEL AND BLADDER:REGU