This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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 55 year old male came to opd with chief complaints of burning sensation of whole body since one week and fever since 1 day.
History of presenting illness:
Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).
He also have complaints of fever since today afternoon associated with chills , relieved on medication.
H/o of burning micturition since 4-5 days
No H/o decreased sensations
No h/o bowel and bladder incontinence.
No h/o seizure activity
No H/O cold, cough, sore throat
No H/o nausea , vomiting, pain abdomen.
No H/o loose stools
PAST HISTORY:
GENERAL EXAMINATION:
SYSTEMIC EXAMINATION
INVESTIGATIONS:
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