80 Y/M with fever, b/l lower limb weakness , pain abdomen, hiccough.


This is an online E- log book 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 available global online community of experts with an aim to solve those patient's 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.

CONSENT AND DEIDENTIFICATION :
 
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piec
e of work whomsoever.


Chief Complaints:
Patient presented with c/o fever since 4 days, cough and cold since since 4 days. Pain and weakness of both lower limbs since 4 days.
Pain abdomen, not passing stool since 4 days, hiccoughs since 4 days.

History Of Present Illness:
Fever High grade, periodic, associated with chills and rigors, no h/o vomiting, diarrhoea.
Cough and Cold - sudden in onset , not associated with sputum and shortness of breath.
Pain and weakness of both lower limbs gradual in onset.

Pain in the epigastric area since 4 days, not taking food since 4 days, associated with hiccoughs.

No H/o DM, HTN , TB, asthma, Epilepsy
No Family H/O HTN, TB, Asthma
No significant surgical History.

Personal History:
Farmer by occupation not working since many years.
Appetite: Reduced since 4 days
Diet: Mixed
Bowels: Constipation since 4 days
Micturition: Normal
No known Allergies
Alcohol- Occassional Last drink- 4 days ago
Tobacco - Smoker

Physical Examination:
Patient is c/c/c
Thinly built
No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy.
Temp: 99 F
Pulse:80 bpm
RR: 20
BP: 110/80
SpO2 at Room air 100%
GRBS: 132 mg %


Systemic Examination
CVS:
S1 S2 Heard , No murmurs

RS:
Trachea: Central in position 
B/L AE+
Normal Vesicular Breath Sounds heard
No Adventitious Sounds

Abdomen:
Scaphoid in shape
Epigastric tenderness +
No organomegaly
No scars or sinuses
Hernial orifices Normal

CNS:
Conscious, coherent, cooperative.

CN-





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