52 Year old male patient with fever and decreased appetite.

hThis is an online E logbook 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 an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio⁴.. and your valuable inputs on the comment box are 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 diagnosis and treatment plan.


Date of Admission 30/10/22




52 Year old male came to Casuality with chief complaints of Fever since 1week associated with Generalised Weakness and Decreased appetite and Vomitings Following food Intake.History of wt loss of 5kg in Last 5 months.

History of Back Pain since 1 month.


History of Presenting Illness


Patient was Apparently asymptomatic 1 month back then he was Having Decreased appetite and then 1 week back He developed Fever which was of intermittent type and was Relieved on medication.It was also Associated with Generalised Weakness and Vomitings Following food intake.He also Has history of Back Pain Since 1 month.


Past History


Not A K/C/O DM,HTN,Asthma,Epilepsy.

No Allergies 

No Past Surgical History

Personal History 

Diet -Mixed

Appeteite- Decreased 

Bowel And Bladder Movements Regular

Addictions Absent


Family History

No Significant Family History.


Vitals

Bp 120/90

Pulse82

RR 15cpm

GRBS 112 mg/dl

General Examination

Pallor -Present

Icterus - Absent

Clubbing - Absent

Koilonychia - Spoon Shaped Fingers

Lymphadenopathy -Left Supra clavicular      Lymphnode Enlarged


Systemic Examination

CVS

S1 S2 Heard 

RS

BAE Present

P/A

Soft ,Non Tender.


Provisional Diagnosis :

Iron Defeciency Anaemia secondary to Chronic Disease ? Secondary to Malignancy ?

Left Supraclavicular Lymphnode Enlarged



Investigation

Chest X Ray :

Skull lateral and Waters View to rule out Multiple Myeloma

LS Spine AP and Lateral View to rule out Any Metastatis as Patient is Complaining of Back Pain


ECG - No Abnormality Detected

29-10-22


30-10-22


Treatment

Inj Iron Sucrose100mg in 100 ml NS Iv BD

Inj Zofer 4m IV TID

Tab Baclofen 10mg BD

Inj Metoclopromide 10 mg Po BD






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