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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
A 80 YR OLD MALE PATIENT CAME TO GM OPD WITH
C/O FEVER SINCE 3 DAYS
C/O GIDDINESS SINCE 3 DAYS
HOPI:
PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK THEN DEVELOPED FEVER LOWGRADE, CONTINUOUS, NOT A/W CHILLS AND RIGORS
C/O GIDDINESS INSIDIOUS ONSET ASSOCIATED WITH CHANGES IN POSITION , MORE IN SLEEPING POSTURE AND BENDING FORWARD A/W NAUSEA, VOMITING 1 EPISODE YESTERDAY NIGHT.
H/O COUGH WITH SPUTUM, MUCOID CONSISTENCY, NON FOUL SMELLING
H/O SOB
NO H/O CHEST PAIN , ABDOMINAL PAIN
NO H/O PEDAL EDEMA
NO H/O BLACK OUTS, TRAUMA
NO H/O EAR PAIN, PUS DISCHARGE FROM EAR
PAST HISTORY:
K/C/O HYPERTENSION SINCE 5 YEARS ON TAB AMLO 5 MG PO OD
N/K/C/O DM, CVA, CAD, EPILEPSY, ASTHMA, THYROID DISORDER
PERSONAL HISTORY:
DIET:MIXED
SLEEP:ADEQUATE
BOWEL AND BLADDER:REGULAR
ADDICTIONS:NO
APPETITE:NORMAL
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME,PLACE AND PERSON.
NO PALLOR,ICTERUS CYANOSIS, CLUBBING , LYMPHADENOPATHY ,EDEMA.
VITALS:
TEMPERATURE:98
BP: 100 /70 MM HG
PR:82 BPM
RR:18 CPM
SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD NO MURMURS.
RS:BAE +,NVBS +
PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY
CNS: HIGHER MENTAL FUNCTION PRESENT,
CEREBELLAR FUNCTION TEST
FINGER NOSE COORDINATION PRESENT
FINGER FINGER COORDINATION PRESENT
KNEE HEEL TEST NEGATIVE
DYS DIADOKINESIA ABSENT
ROMBERG TEST NEGATIVE
NYSTAGMUS - VERTICAL IN SUPINE POSITION FOR 10 SEC
https://youtu.be/QwmvMeMjo0o?si=GjPP82KpvPOW-OHD
ENT REFERRAL DONE ON 27/1/24 I/V/O NYSTAGMAS:
ADVICE:
UNABLE TO PERFORM DIX HALPIK MANEUVER AND HEAD IMPULSE TEST I/V/O SEVERE NECK PAIN .
KINDLY CONTINUE SAME MEDICATION AS ADVISED BY PRIMARY PHYSICIAN
OPTHAL REFERRAL DONE ON 27/1/24 I/V/O REFRACTORY ERROR IN B/L EYES:
VA : RE-6/60. 6/24 ; LE -6/60. 6/36
ADVICE: USE SPECTACLES AND REVIEW TO OPTHALMOLOGY OPD AFTER 3 MONTHS
INVESTIGATIONS:
HBsAg- RAPID : Negative
Anti HCV Antibodies - Non Reactive
POST LUNCH BLOOD SUGAR:126 mg/dl
RFT :
UREA 18 mg/dl 50-17 mg/dl
CREATININE 1.3 mg/dl
URIC ACID 4.0 mg/dl
CALCIUM 10.1 mg/dl
PHOSPHOROUS 3.9 mg/dl
SODIUM 135 mEq/L
POTASSIUM 4.4 mEq/L
CHLORIDE 102 mEq/L
LIVER FUNCTION TEST (LFT) :
Total Bilirubin 0.63 mg/dl
Direct Bilirubin 0.16 mg/dl
SGOT(AST) 12 IU/L
SGPT(ALT) 10 IU/L
ALKALINE PHOSPHATE 136 IU/L
TOTAL PROTEINS 7.2 gm/dl
ALBUMIN 3.8 gm/dl
A/G RATIO 1.13
HEMOGRAM:
HB:13.7
TLC: 4,000
PLATELETS: 2.67
CUE:
COLOUR: PALE YELLOW
ALBUMIN: NIL
SUGARS: NIL
PUS CELLS: 1-2
PROVISIONAL DIAGNOSIS:
BENING PAROXYSMAL POSITIONAL VERTIGO.
BILATERAL SENSORY NEURAL HEARING LOSS
HYPERTENSION
TREATMENT:
TAB SPIN FREE BD 1--0--1 FOR 1 WEEK
TAB PAN MG PO OD
TAB DYTOR PLUS 10/50 PO OD 9 AM--0--0 FOR 3 DAYS
TAB ULTRACET BD 1--0--1` FOR 5 DAYS
TAB SHELCAL CT PO OD 0--1--0 FOR 15 DAYS
CERVICAL SOFT COLLAR APPLICATION
NECK STRENGTHING EXERCISES
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