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 37year old women, housewife who is a resident of Kolkata came with the chief complaints of pain in the back of the neck and lower back since 1year and chest pain 2 weeks back.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 years back then she had
Daily routine:
She wakes up at 6 am and cooks for herself and her family and do her household chores and has breakfast at 9am and lunch at 1pm and dinner at 9pm then sleeps by 10pm.
PAST HISTORY:
she is a known case of Hypertension since 6 years.
K/c/o CVA 6 years back.
She is not a known case of asthma, diabetes,TB.
PERSONAL HISTORY:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular Addictons-none
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. moderately built and nourished.
Pallor-absent
Icterus-absent
Clubbing-absent
Cyanosis-absent
Generalised lymphadenopathy-absent
Pedal edema-absent
Vitals:
Temperature- degree F
Pulse rate- bpm
Respiratory rate-cpm
Blood pressure -mm of hg
Spo2-%at room air
Grbs-mg /dl
SYSTEMIC EXAMINATION:
Cardiovascular system:
S1 and S2 heard no murmurs heard
Central nervous system:
No focal neurological deficit, cranial nerve intact
Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard
Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable.
Provisional diagnosis:
Post stroke and post MI secondary to hyperlipidemia and Hypertension
Investigations:
ECG:
2D echo heart:
Treatment:
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