GM -11
Hi, I am P.Aishwarya, 5th sem 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 this piece of work whatever.
Chief Complaint:
A 78 year old female resident of chityal farmer by occupation came to OPD with chief complaints of
-Diminution of vision in both the eyes since 2 years
-pain in the right hand since 10 days
-fever since today evening
-tinnitus in the right ear since 5 years
History of Present Illness:
-Patient was apparently asymptomatic 2 years ago then she had developed bilateral diminution of vision which is gradually progressive, blurring of vision present and diplopia absent.
-Right hand pain since 10 days ,no tingling sensation and no burning sensation.
-Fever since 2 days which is high grade, intermittent,not associated with chills and rigors,and relieved by medication, cold and cough are seen
-No chest pain,SOB, palpitations
-No c/o decreased urinary output,pedal edema,burning micturation,facial puffiness and abdominal distension.
-c/o tinnitus in right ear,no ear pain
-h/o rat bite 10 days back
Daily Routine:
Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.
After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past History:
-No similar complaints in the past
-k/c/o HTN since 1 year using medication T-CLINIDIPINE 5 mg
-not a k/c/o DM,TB,Epilepsy,CAD,CVA, Thyroid disorders.
Surgical history:
No surgical history
Personal History:
- married
- decreased appetite
- mixed diet
- irregular bowels
- abnormal micturition
- no known allergies
- addictions: used to take alcohol and tobacco 6 months back,but stopped now.
Family History: not significant
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- Temperature: afebrile
- Pulse: 82 beats/min
- RR: 20 cycles/min
- BP: 120/80 mm Hg
Spo2: 98%
Fluid Intake and Urine Output
Total Input: ml
Total Output: ml
Fever Chart
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- no wheeze
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals:
- speculum examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
USG:
ECG:
Provisional Diagnosis:
1.Right upper limb cellulitis secondary to rat bite.
2.Chronic kidney disease
3.Anemia secondary to chronic kidney disease.
4.bilateral immature senile cataract
5.k/c/o hypertension since 1 year
Treatment:
TAB.PCM 650 mg
TAB.NODOSIS 500 mg
TAB.SHELCAL
TAB.MVT
TAB.OROFER XT
SYP.ARISTOZYME
Inj.CEFTRIAXONE 500 mg
TAB.CHYMORAL FORTE
