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

Popular posts from this blog

A 38 yr old male with fever ,cold cough, generalized weakness,headache,SOB

Image
A 38 yr old male with fever ,cold cough, generalized weakness,headache,SOB September 11, 2022   Hello, I am Y.Varunkarthik ,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio This is a case of 38 year old male came with cheif complaints of  1.Fever with chills 2.cold 3.Cough 4.Generalized weakness 5.Head ache(frontal region) 6.SOB grade 2 7. Loose stools History of presenting illness: Patient was apparently asymptomatic 4days back. Then he developed fever which was high grade fever with chills which eas intermittent relieved by medication associated with cold,cough which is dry in nature and generalized weakness. Since 1 day he has complaints og loose stools of 5 episodes which is watery and non blood stained and non mucoid.No complaints of pian abdomen or vomitings. PAST HISTORY :- Not a known case of HTN/DM, /Thyroid disorder/TB/Asthma/CAD PERSON
Read more

72years old female with dov of right and left eye ,knee pain and hypertension

Image
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
Read more

OPD3- 55 years male with chief Complaint of hypertension and c/o hemorrhoids

Image
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
Read more