This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed 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 49 year old female farmer by occupation and hailing from devarakonda
CHIEF COMPLAINTS:
Headache since 1year
Decreased urine output since 20days
Bilateral lower back pain since 15days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 year back then she developed headache which is insidious in onset and gradually progressive in nature and it aggrevates on bending forward and relieved temporarily on medication. The episodes of headache have aggrevated over the past 3 days, around 4 episodes/day and each episode lasting for 1-2hrs and is relieved on medication. Headache is diffuse, throbbing type and is affecting the daily life of the patient. It is associated with photophobia, phonophobia and nausea.
It is not associated with fever, vomitings, lacrimation.
She was diagnosed with a deviated nasal septum towards the right side with associated left maxillary sinusitis 2 months back.
Patient also has bilateral loin pain from past 15 days which is insidious in onset, non-progressive. It is associated with decreased urine output for the past 15 days. She is also experiencing burning micturition.
DAILY ROUTINE:
She wakes up at 4'oclock in the morning and does her daily routine activities like cleaning the house, cooking. She then goes to cotton fields at 9'oclock in the morning and works there till evening.
She has her lunch in the fields itself at around 1'oclock in the afternoon and comes back to home at 5'o clock. Then she prepares dinner for her family and has her dinner around 9'o clock.
PAST HISTORY:
She is a known case of hypertension since 1 year on Tab. Amlodipine 5mg.
No similar complaints in the past
No history of DM,CAD,CVD,TB, Asthma and epilepsy
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Diet:mixed
Appetite:normal
Sleep: adequate
Bowel movements were regular but there is decreased urine output and burning micturition is present.
No addictions
No allergies
DRUG HISTORY:
She is a known case of hypertension and on TAB. AMLONG 5mg
SURGICAL HISTORY:
She underwent hysterectomy 15yrs back.
GENERAL EXAMINATION:
I had taken prior informed consent of the patient and examined in a well lit room
Patient is conscious ,coherent and cooperative moderately built and moderately nourished
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-Absent
●She is having Deviated nasal septum towards right side.
VITALS:
TEMPERATURE: AFEBRILE
BLOOD PRESSURE:150/100mmHg
PULSE RATE:83bpm
RESPIRATORY RATE:14cpm
SYSTEMIC EXAMINATION:
•CARDIOVASCULAR SYSTEM:S1 S2 HEARD AND NO MURMURS
•RESPIRATORY SYSTEM:BAE+ NVBS HEARD
•PER ABDOMEN EXAMINATION: Right loin tenderness present.
•CENTRAL NERVOUS SYSTEM EXAMINATION:
1)HIGHER MENTAL FUNCTIONS: - The patient is conscious, appears comfortable, language and behaviour appears normal.
- Orientation to time place and person normal. Mood and emotional status appears normal.
- Memory: immediate, recent and remote memory tested- normal.
- Appearance- no tics, tremors, myoclonus, involuntary or voluntary movements
2)CRANIAL NERVES- right. Left
1.OLFACTORY NERVE:
Sense of smell - normal. Normal
2.OPTIC NERVE:
Visual acuity - normal Normal
Field of vision- normal Normal
colour vision. Normal. Normal
3.OCULOMOTOR NERVE
4.TROCHLEAR NERVE
6.ABDUCENS NERVE :
-extra ocular movements:Normal
-pupils: Normal size and reacting to light on both sides
-direct and consensual light reflexes normal in both eyes
No Nystagmus
no ptosis
5.TRIGEMINAL NERVE:
Sensory : sensations over face normal on both sides
Motor - massater,temporarils, pterygoids normal
7. FACIAL NERVE:
Motor : Nasolabial fold,Orbicularis oculi, orbicularis Oris ,occipital frontalis,
buccinator -normal on both sides
Sensory : taste over anterior 2/3rd of tongue normal on both sides
8. VESTIBULOCOCHLEAR NERVE:
Rinnes test normal on both sides
. Webers test normal on both sides
9.GLOSSOPHARYNGEAL NERVE
10.VAGUS NERVE:
Uvula , palatal arch movements normal.
Gag reflex. - normal
Palatal reflex - normal
11. SPINAL ACCESSORY NERVE:
Tarpezium and sternocleidomastoid -normal
12. HYPOGLOSSAL NERVE:
No wasting and fasciculations of tongue
Tongue protrusion to midline.
3)MOTOR SYSTEM:
Bulk:normal on both upper and lower limbs
Tone:normal on both upper and lower limbs
Power:5/5 on both upper and lower limbs
4)REFLEXES:
•Bicpes:
•Triceps:
•supinator:
•Knee:
•Ankle:
•BABINSKI'S SIGN
VI – GAIT-Normal
6)AUTONOMIC NERVOUS SYSTEM
Postural Hypotension-absent
Resting tachycardia-absent
Abnormal sweating-absent
7)SIGNS OF MENINGEAL IRRITATION
Neck stiffness-absent
Kernigs sign-negative
Brudzinskis sign-negative
8) EXAMINATION OF SPINE AND CRANIUM
SPINE bony deformities, bruit, tenderness-absent
CRANIUM bony abnormalities, bruit-absent
10)CAROTID PULSE-normal
INVESTIGATIONS:
HEMOGRAM:
Hb:13.0
RBC:4.15
TLC:5,800
NEUTROPHILS:59
LYMPHOCYTES:35
EOSINOPHILS:01
MONOCYTES:05
BASOPHILS:00
PCV:37.1
MCV:89.4
MCHC:35.0
RDW:11.6
PLT:3.01
URINE EXAMINATION
COLOUR:PALE YELLOW
APPEARANCE:CLEAR
SPECIFIC GRAVITY:1.010
ELECTROLYTES
Na+=137
K+=3.8
Cl-=102
Ca+=1.00
-ECG:
CHEST X-RAY:
PROVISIONAL DIAGNOSIS:
Headache under evaluation.(MIGRAINE?)
TREATMENT:
1)TAB.NAXDOM 250mg/PO/BD
2)BP monitoring and charting every 4th hourly.
DISCUSSION.
My probable diagnosis could be migraine because of this following criteria
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