A 60 year old male patient brought to casualty with high fever and weakness of upper left limb.
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.
This E blog also reflects my patient cantered 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.
This is the case of male farmer residing in pthallapalam , Suryapet.
Cheif complanits
-high grade fever since 10days
-weakness of upper left limb (10 days)
-dry cough from 2 days
- decreased micturation since 7 days
History of presenting illness
-Patient was apparently asymptomatic 10days back , he had high grade fever 10days ago with chills and rigors.
-history of dry cough (2 days)
-weakness in left upper limb with sudden onset
- decreased micturation since 7 days
Past history
Patient was admitted in Miryalguda private hospital for the same and was treated with medication.
-H/O loose for 2 days (while he was in the hospital)
-H/O diabetes since 10 years
- H/O hypertension since 10 years
-N/H/O of CAD , Asthama, Tb, Antibiotics , Radiation, blood transfusion and surgeries.
Personal History.
Mixed diet
No addictions to alcohol, tobacco , drugs , beetle leaf .
No significant family history
General Examination
Patient is conscious , coherent and cooperative.
Pateint is examined in a well lit room with consent
Slightly pallor
No cyanosis 
VITALS:
Temperature- 98.4°F
BP-120/70 mmhg
PR-82bpm
RS-BAE+
No associated pain
SYSTEMIC EXAMINATION:
CVS- S1S2 heard and no murmurs heard.
INVESTIGATIONS :
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