This is K.Vinila Bhavani , 8 th sem student .This Elog depicts patient centred approach to learning. This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.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 diagnosis and treatment plan.
A 40 yr old male patient , resident of mirualguda , who is daily wage labourer by occupation came to OPD with chieft complaints of pain abdomen since 5 days associated with fever since 2 days . History of present illness Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .Pain is relieved on medication . No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB . History of past illness N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders . Personal history Diet - mixed Appetite- normal Bowel and bladder -regular Sleep - adequate Addictions - regular alcohol intake of 250 ml per day since 20 yrs . No food allergies and drug allergies Family history Not significant General examination Pallor - yes Edema - no Clubbing - no Lymphadenopathy - no Icterus - no Vitals - Temperature - 100.1F BP-85/60