A 65YEARS OLD FEMALE CAME WITH THE CHIEF COMPLAINTS OF FEVER, COUGH AND LOWER BACK PAIN

This is an online E log book by Faizal.m  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-centred online learning portfolio and your valuable comments on comment box is 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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS:

A 65 year old female patient came with the chief complaints of:
- fever, cough since 12days
-lower back pain since 35year
HOPI:-

The patient was apparently asymptomatic 12 days back. He then complained of fever, insidious in onset, intermittent in nature, cough associated with sputum which is continuous
65years back she has a history of trauma (she fell on well)
Then she had lower Bach pain and headache 
No aggrevating and relieving factors.
No history of vomiting,diarrhea, constipation
No history of night sweats and chills and rigors.
No history of headache
No history of burning micturition

PAST HISTORY:
She is known case of diabetic and under medication since 3year
Not a known case of asthma, hypertension, tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.
No similar complaints in the past
No previous surgical history

PERSONAL HISTORY:


Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: nirmal
Habits: occasional alcoholic (200ml)
No history of allergy

Family history:
Insignificant

GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished
pallor present 
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration

VITALS:

Temperature: febrile

Pulse: 32beats per minute, regular

Respiratory rate: 14 cycles per minute

Blood pressure: 130/90 mm of Hg

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