This 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 portfolio 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

Case Presentation
30 Year old Female , Shepherd  by Occupation resident of Nalgonda,came to casuality with chief complaints of Fever and chills since 10 days with evening rise of temperature and was Relieved on Taking Medication.It was also associated with Nausea and Loss of appetite.She was Not able to Go to Work since 3 days.There is H/o 1 episode of Burning Micturition 5 days Back.No Constipation.No Shortness Of Breath.No Bleeding Per Rectum.
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.
Provisional Diagnosis :
Viral Pyrexia

Vitals
Bp 110/60 mmHg
Pulse 78BPM
RR 16cpm
GRBS 110 mg/dl

Systemic Examination
CVS
S1 S2 Heard 
RS
BAE Present
P/A
Soft ,Non Tender.

Investigation
Chest X Ray :

Treatment 
Inj Ceftriaxone Iv BD
Tab Doxycycline PO BD
Inj Zofer IV TID
Tab Pan 40 mg

SOAP Notes Day 1
Complaints

Fever And Chills 
Decreased Appetite
Vitals
Bp 100/60 mmHg
PR 60 BPM
Temp 100.6 F at 8am
CVS S1 S2 Heard
RS BAE Present

Diagnosis. - Viral Pyrexia

Inj Ceftriaxone Iv BD
Tab Doxycycline PO BD
Inj Zofer IV TID
Tab Pan 40 mg

Soap Notes Day 2
Complaints

Fever And Chills 
Decreased Appetite
Vitals
Bp 130/70 mmHg
PR 84 BPM
Temp 100.1F at 8am
CVS S1 S2 Heard
RS BAE Present

Diagnosis. - Viral Pyrexia

Inj Ceftriaxone Iv BD
Tab Doxycycline PO BD
Inj Zofer IV TID
Tab Pan 40 mg
Inj Neomol 1gm IV SOS
Tab PCM 650mg QID






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