This is an a 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.
Case:
A 70 year old female resident of nalgonda came to casualty with c/o lump on the left lower gluteal region 7 days back, sob since 4 days, vomitings 3days back and loose stools 3 days back.
Hopi:
Patient was apparently asymptomatic 4 years back then she was diagnosed with Hypertension on regular checkup for which she is on medication(unknown).
She also developed sob 4 days back, initially she has dyspnea on walking for short distances (grade 3) which progressed to grade 4(dyspneic even at rest).
She had 3-4 episodes of vomitings 3 days back which were non projectile and non bilious, food particles as content.
she also had loose stools 2-3 episodes.
she noticed a lump on lower gluteal region a week ago which was 2×2 cm in size which progressed to the current size of 5×5 cm.
History of palpitations since childhood usually during summer.
No history of cough, fever, chest pain, abdominal pain, orthopnea, PND, syncopal attacks.
Past history:
No history of similar complaints in th past.
She is a known case of Hypertension for past 2 years for which she is on medication(unknown).
Not a known case of diabetes mellitus, asthma, epilepsy, Thyroid disorders, TB, CAD.
Surgical history:
Hysterectomy done for fibroid uterus in 2006.
Family history: not significant.
Personal history:
Diet- mixed
Appetite- Normal
Sleep- Adequate
Bowel and bladder movement: Regular
Addictions: Toddy, occasionally.
General examination:
Patient is conscious, coherent, and cooperative.
She is moderately built and moderately nourished.
Oriented to time,place,person.
Vitals:
Temperature-afebrile.
PR-114 bpm.
BP-90/60 mm of hg.
RR-32 cpm.
Spo2- 95% at room air.
No pallor
Inspection-
Chest wall- symmetrical
No Precordial bulge, Pectus carinatum/excavatum, scar, sinuses.
Parasternal heaves absent.
Apical impulse-absent.
No raised JVP.
Palpation-
Apical impulse- localized and present in the 5th intercostal space in the mid clavicular line.
Auscultation-
S1, S2 heard ; no murmurs heard.
Respiratory system:
BAE- present
Normal vesicular breath sounds heard.
Abdomen:Basal crepitations heard.
shape - obese
soft,and non tender.
Bowel sounds heard.
CNS:
No focal neurological deficit
Investigations:
CBP-
ECG-
on 5-2-2022
On 6-2-2022
On 7-2-2022
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