35 year old female patient with fever,chills and cough

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This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan.


Following is the view of my case:
CASE:

A 35 year old female patient came to OPD with chief complaints of cold since 3 days,fever,chills and cough since 2 days

History of presenting illness:

Past History:

Gestational History:

Personal History:

On examination:

Vitals:


Investigations:
Blood urea:
Liver function tests:
Serum Calcium:
Serum creatinine:
Hemogram:
ECG:
Colour Doppler 2D ECHO:
Ultrasound scanning:
Serum electrolytes:
Complete urine examination:
Lipid profile:
serum electrolytes:
Hemogram:

Provisional diagnosis:
Hypertensive Urgency
Treatment:

Tab.

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