52 year male loin pain and sob

August 29, 2022

August 28, 2022

This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 come up with a diagnosis and treatment plan.

Our 52yr old male patient came to the casuality with chief complaints of

C/o fever since 10days

C/o Rt loin pain since 1week

C/o cough with sputum since 1week

C/o sob since 3days

Hopi:

Patient was apparently asymptomatic 10days ago then he developed fever which is low grade ,not associated with chills &Rigors which is aggrevated at night.3 days later he climbed a tree and had a fall from the tree following which he had injury to the low back .since then he has developed Rt loin pain for which he was taken to local hospital where radiological investigations were done & no abnormality was detected .pain was not decreasing since then .After 3 days he developed abdominal discomfort associated with SOB which is on & off & cough with sputum which is white in colour for 1 week.

H/O vomitings -1 episode 3 days ago

No h/o burning micturition

PAST HISTORY:-

Known case of HTN since 6 yrs for which he is on medication.

Not a known case of DM, Epilepsy,CAD.

Family history:

Not significant

General examination:

Patient is c/c/c

Temp:

BP: 100/60mmhg

PR: 82bpm