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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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
13-NOVEMBER-2023
63 Y/F came to opd with C/O
Giddiness and headache since 3 months
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 months ago, then developed giddiness which is present with positional variation
Tinnitus in right ear +
No hearing loss
Associated with nausea.
No h/o vomitings
Headache since 3 months(bilateral parietal region)
No h/o photophobia, phonophobia
H/o chest tightness+ , occasionally
No h/o chest pain and palpitations
PAST HISTORY
K/c/o HTN, Since 13 years . On losartan 50 mg, hydrochlorothiazide 12.5 mg
N/k/c/o CAD since 1 year
N/K/C/O DM, BA, TB , CVA , Leprosy, Epilepsy, Thyroid disorders.
PERSONAL HISTORY
Married
Mixed diet
Normal Appetite
Regular Bowel and bladder
No allergies, addictions.
FAMILY HISTORY
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative,well oriented to time,place and person.
Moderately build and well nourished.
Examination was done in a well lit room.
No pallor, cyanosis,clubbing,lymphadenopathy, pedal edema, icterus
Vitals
PR- 82 bpm
BP- 120/60 mm Hg
RR- 20 cpm
Afebrile
GRBS - 105 mg/dl
SYSTEMIC EXAMINATION
ABDOMEN
Inspection
Shape - Slightly distention.
Umbilicus - Everted
Equal movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
No scars , sinuses
Palpation
Soft, non tender
Auscultation
Bowel sounds heard
RESPIRATORY SYSTEM
Bilateral air entry present
CVS EXAMINATION
S1 S2 heard, no murmurs
CNS EXAMINATION
No focal neurological deficits
Higher mental functions normal
Cranial nerves normal
Sensory examination normal sensations
Motor examination normal
Reflexes normal
Investigation
RFT
UREA16 mg/dl
CREATININE0.6 mg/dl
URIC ACID 4.0 mg/dl
CALCIUM 10.0 mg/dl
PHOSPHOROUS 3.7 mg/dl
SODIUM 141 mEq/L
POTASSIUM 3.9 mEq/L
CHLORIDE 98mEq/L
LIVER FUNCTION TEST (LFT)
Total Bilurubin 0.84m g/dl
Direct Bilurubin0.19 mg/dl
SGOT(AST)16 IU/L
SGPT(ALT)10 IU/L
ALKALINE PHOSPHATE193 IU/L
TOTAL PROTEINS7.6 gm/dl
ALBUMIN4.45 gm/dl
A/G RATIO1.41
COMPLETE URINE EXAMINATION (CUE)
COLOUR. Pale Yellow
Appearance Clear
REACTIONAcidic
SP.GRAVITY1.010
ALBUMIN Nil
SUGAR Nil
BILESALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2-3
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERSNil
HEMOGRAM
HB 11.4
TLC 7300
N/L/E/M/B 52/42/1/5/0
PLATELETS 3.35 LAKHS/CC
NORMOCYTIC NORMOCHROMIC
2 D ECHO
NO AR/TR, TRIVAL MR+
RWMA+ LAD AKINETIC TARITARY+ , NO AS/MS
MODERATE LV DYSFUNCTION+
DIASTOLIC DYSFUNCTION+ NO PAH/PE, EF 41%
TREATMENT -
TAB LOSARTAN 50 MG + TAB HYDROCHLORTHIAZIDE 12.5 MG PO OD
TAB. ECOSPRIN AV 75/20 PO OD
TAB . DYTOR 10 MG PO BD
Advice at Discharge
TAB LOSARTAN 50 MG + TAB HYDROCHLORTHIAZIDE 12.5 MG PO OD
TAB. ECOSPRIN AV 75/20 PO OD
TAB . DYTOR 10 MG PO BD
TAB MVT PO/OD X7DAYS
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