Hi , I am Samhitha ,5th semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

Hi, I am p.samhitha, 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 patient's 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 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 a diagnosis and treatment plan.

CHIEF COMPLAINTS 

Pt came with 

-c/o giddiness since 1 yr

-c/o headache since 1 yr

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 1 yr ago then she developed giddiness which is associated with sweating palpitations 

C/o headache which is throbbing in temporal region and not associated with photophobia phonophobia and nausea

No h/o giddiness aggravating with neck movements earache and tinnitus 

No h/o vomiting fever loose stools pain abdomen cough cold

No h/o slurring of speech limb weakness deviation of mouth

No h/o sob chest pain palpitations orthopnea pnd

PAST HISTORY:

K/C/O DM 2 since 1 yr (on tab metformin 500 mg) ,HTN since 1 yr (on omlesartan 20 mg )and CVA since 1 yr (on atrozio gold (atrovastatin clopidogrel and aspirin)) 

(CT scan - B/l periventricular white matter hypodensities ? Chronic Ischemic changes 

Multiple small calcific foci in the frontal and b/l parietal region)

N/k/c/o TB , Epilepsy, CAD

PERSONAL HISTORY:

Diet - Mixed

Appetite - Normal

Bowel and Bladder movements- Regular

Sleep - Adequate 

Addictions - None

FAMILY HISTORY-

Not significant

GENRAL EXAMINATION-

Pt is c/c/c well oriented to time place and person 

No signs of pallor icterus cyanosis clubbing lymphadenopathy edema 

Temp - Afebrile

PR - 78bpm

RR - 18cpm

BP - 110/80mmhg

Spo2 - 98RA

GRBS - mg%

Clinical Pictures-

SYSTEMIC EXAMINATION-

CVS -

S1 S2 +

No thrills felt

No murmurs heard

RS -

B/l air entry +

Position of trachea central

No wheeze or rhonchi

P/A-

Shape - scphaoid

No tenderness or organomegaly present

CNS-

She is conscious coherent and cooperative 

No signs of meningeal irritation 

Motor System-

GCS 15/15 - E4V5M6

Power-

                           R. L. 

U/l 5/5. 5/5

L/l. 5/5. 5/5

Tone-

U/l. N. N

L/l. N. N

Reflexes-

B. +. +

T. + +

K. - -

A. - -

Plantar Flexor. Flexor

PROVISIONAL DIAGNOSIS-

Giddiness under evaluation ?Hypoglycemia

H/o CVA 1 yr ago

INVESTIGATIONS-

CUE -

Alb - Nil

Sugar - Nil

Pus cells - 1-2

Epithelial cells - 2-3

Rbc - nil

HEMOGRAM-

Hb - 8.4

Tlc - 5900

Platlets - 2.88

Rbs - 117

Blood urea - 42

Sr . Creat - 1.5

USG -

B/l Grade 1 RPD changes

Grade 1 Fatty liver

2D echo -

Trivial TR

No MR AR

No RWMA 

No AS/MS sclerotic

Good LV systolic function

Diastolic dysfunction

No 

Ecg-

Chest X-Ray

PLAN OF TREATMENT-

Tab Ecosprin PO/OD 

Tab Metformin 500 mg

Tab Omelsartan 20 mg