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.
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. CHIEF COMPLAINTS: A 35 year old male patient came to casualty with chief complaints of 1:SOB Since 7-10days 2: Palpitations since 7days 3:Pedal edema since 2days HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 10days back then he developed sob which was started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest(grade-4). Associated with increase during sleeping position and relieved ...
OP COMPOUND POISONING 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 A 65 year old male patient came to casualty with Consumption( profenofes) OP compound around 40 ml on 3/2/21 at Chityala Patient was brought to casualty at 4.30 p. m. On 3rd feb H/o 2episodes of vomitings No h/o involuntary micturition/loose stools 7th feb He also complained of left leg pain He also complained of dry cough and chest pain PAST HISTORY N/k/c/o DM,HTN,CAD,Asthma PERSONAL HISTORY Diet:mixed Appetite:normal Sleep: adequate Bowel an...
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