OPD2-62 years old female came to OPD with the chief complaint of headache since 15 days ,fever and chest pain since 5days.
Hi, I am Y.Varunkarthik , 5th semester medical student.
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 patients 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 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Chief Complaint
62 years old female came to OPD with the chief complaint of headache since 15 days ,fever and chest pain since 5days.
History of Present illness
Patient was apparently asymptomatic 15 ago then she developed severe headache which was insidious in onsetand dragging type of pain , aggravated while bending and radiating to neck.
Later she developed chest pain 5 days back which was sudden in onset , continuous and dragging type of pain, aggravated by coughing and sleeping .
Fever since 5days sudden , intermittent and high grade usually relieved by medication associated with nausea and loss of appetite.
Productive cough -white sputum ,thick consistency.
History of past illness:
N/k/c/o diabetes,/hypertension/epilepsy, thyroid disorders/asthma/ cad
H/o head injury on temporal side 10years back.
Treatment history:
H/o ent surgery 6 years back
Personal history:
Married ,
Mixed diet ,
Loss of appetite,
Inadequate sleep.
Regular bowel and bladder movements.
No addictions.
Family history: Not significant
General examination:
Patient was conscious, coherent and cooperative.
No pallor ,icterus, cyanosis,clubbing of fingers, lymphadenopathy,pedal edema
Vitals:
Temp: afebrile
PR:88bpm
RR:22rpm
BP:110/70 mmhg
Systemic examination
CVS:
No thrills
S1,S2 are heard
No murmurs
Respiratory examination:
- Dyspnoea
- No wheezing
- central trachea
- vesicular breath sounds
-Bilateral basal crepts
ABDOMEN
- scaphoid shaped abdomen
- No tenderness
- No palpable mass
- non palpable liver and spleen
CNS
- conscious and coherent
- normal speech
Investigation:
ECG -
Hemogram-
Treatment
1)Inj .neomol 1gm I.v/sos
2)Tab.pcm 650 mg po/tid
3)Syrup.ascoryl- ls po/tid
