Jyothi Reddy 44

 Diagnosis IRON DEFICIENCY ANEMIA TO BLOOD LOSS (ANAL FISSURE) Case History and Clinical Findings C/O HEADCHE SINCE 1 WEEK C/O VOMITINGS 2 DAYS BACK C/O HEAVINESS OF CHEST SINCE 2 DAYS PT WAS APPARENTLY ASYMPTOMATIC 1MONTH BACK THEN SHE HAD 2 EPISODES OF VOMITING TREATED SYMPTOMATICALLY A/W HEADACHE NON PROJECTILE NON BILIOUS FOOD PARTICLES CONTENT MENSTRUAL HISTORY - 3 DAYS/30DAYS CLOTS - , PAIN - H/O IRREGULAR MENSTRUATION CYCLES MENARCHE AT 17Y NO H/O CHEST PAIN, SHORTNESS OF BREATH ,PAIN ABDOMEN ,LOOSE STOOLS, NAUSEA+ ,VOMITING -, FEVER -, WORM INFESTATION - ,PICA- H/O BLEEDING PER RECTUM 1 EPISODE - TODAY [FEW RED DROPS IN STOOL] -HEMOPTYSIS -, HEMETEMESIS - ,BLEEDING GUMS HEADACHE - UNILATERAL THROBBING TYPE NON RADIATING - NO NAUSEA , VOMITING , - PHOTOPHOBIA HEAVINESS OF CHEST - NOT A/W FOOD INTAKE NOT A/W EXERTION NUTRITIONAL HISTORY; MORNING - TIFFIN[IDLY , DOSA , BONDA , POORI ] AFTERNOON - SAMBAR /CURRY/CURD+RICE NO SNACKS NIGHT - CURRY/PICKLE/CURD - RICE NO SIMILAR COMPLAI

 Diagnosis IRON DEFICIENCY ANAEMIA Case History and Clinical Findings C/O GENERALIZED WEAKNESS SINCE 7 DAYS C/O FEVER SINCE 7 DAYS C/O HEAD ACHE SINCE 7 DAYS C/O SWELLING OF FACE SINCE 1 DAY PATIENT WAS APPRENTLY ASYMPTOMATIC 7 DAYS AGO THEN DEVELOPED FEVER,LOW GRADE ASSOCIATED WITH CHILLS HEAD ACHE IS BILATERAL(OCCIPUT REGION),PRICKING TYPE INSIDIOUS IN ONSET,GRADUALLY PREGRESSIVE,NO AGGRAVATING OR RELEIVING FACTORS,THEN SHE DEVELOPED SWELLING FOR FACE 1 DAY BACK SUDDEN IN ONSET H/O DYSPNEA 5 DAYS AGO,GRADE III H/O COUGH WITHOUT EXPECTORATION 1 WEEK BACK H/O COLD 1 WEEK BACK NO C/O VOMITINGS,NAUSEA,PHOTOPHOBIA,PHONOPHOBIA,HEAD ACHE FEVER,COUGH,COLD PRESENT NO H/O VOMITINGS,PEDAL EDEMA,INCREASE OR DECRTEASE IN URINATION ,PASSAGE OF LOOSE STOOLS,CONSTIPATION N/K/C/O HTN/DM/TB/ASTHMA/EPILEPSY H/O ONE UNIT PRBC TRANSFUSION 15 YRS AGO GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE PALLOR PRESENT NO CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA TEMPERATURE 98.4 F PULSE

 Diagnosis DIMORPHIC ANAEMIA(BICYTOPENIA) WITH CKD(STAGE 4) WITH 4 SESSIONS OF HEMODIALYSIS DONE(2019) Case History and Clinical Findings COMPLAINTS: 80 YEAR MALE WITH C/O TINGLING AND NUMBNESS OF BOTH UL AND LL SINCE 1 WEEK. HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL LAST WEEK,THEN DEVELOPED HAEMATURIA SINCE LAST FRIDAY, IN EACH EPISODE OF URINE OUTPUT, WHICH LASTED FOR 4 DAYS.NO AGGREVATING FACTORS, NO RELIEVING FACTORS. H/O DECREASED URINE OUTPUT SINCE 1 MONTH, BUT INCREASED FREQUENCY. NO H/O BURNING MICTURITION, HESITANCY OR URGENCY NO H/O BLEEDING MANIFESTATIONS,PETECHIAE,RASH,NO HEMATURIA,NO BLOOD IN STOOL(MELENA),NO BLLEDING GUMS. NO H/O FEVER, COUGH, COLD, PAIN ABDOMEN NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA AND PND TINGLING AND NUMBNESS OF UL AND LL SINCE 1 WEEK. NO POLYPHAGIA,POLYDYPSIA,NOCTURIA POLYURIA PRESENT UROLOGY REFERRAL TAKEN IN VIEW OF HEMATURIA ?URINARY BLADDER CARCINOMA DIAGNOSIS:BPH WITH GRADE 2 RPD CHANGES ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS T.PANTOP 40MG

 Diagnosis FIBROMYALGIA OF RIGHT SHOULDER TRAPEZIUS TENDERNESS ACID PEPTIC DISEASE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY MELESMA +PITYRIASIS VERSICOLOR DENEVO DIABETES MELLITUS DENEVO HYPERTENSION Case History and Clinical Findings C/O RIGHT SHOULDER PAIN SINCE 6MONTHS LOWER BACKACHE SINCE 6 MONTHS CHEST PAIN SINCE 1 WEEK HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC AND ALRIGHT 6 MONTHS BACK AND THEN SHE DEVELOPED SHOULDER PAIN @ RIGHT SIDED OF SUPRASCAPULAR AREA,PAIN+,INSIDIOUS ONSET GRADUALLY PROGRESSIVE,TENDERNESS - ,NO RESTRICTION OF MOVEMENTS,AGGREVATING ON DOING HEAVY WORK AND NO RELIEVING FACTORS A/W LOWER BACK ACHE SINCE 6 MONTHS,PAIN+ ,TENDERNESS- ,AGGREVATING ON BENDING AND WORKING AND RELIEVED BY TAKING REST CHEST PAIN SINCE 1 WEEK AT RETROSTERNAL REGION, EPIGASTRIC REGIONAL PAIN +,BURNING SENSATION +,REGURGITATION -,BELCHINGS -,AGGREVATING ON EATING SPICY FOOD AND NO RELIEVING FACTORS N/H/O FEVER,COLD,COUGH,ALLERGIES N/H/O ABDOMINAL PAIN,NAUSEA,VOMITING,LO

  DIAGNOSIS SEVERE IRON DEFICIENCY ANEMIA SECONDARY TO NUTRITIONAL DEFICIENCY Case History and Clinical Findings 35 YEARS OLD FEMALE, CAME WITH CHIEF COMPLAINTS OF 1) SHORTNESS OF BREATH SINCE 3 MONTHS , 2) FEVER SINCE 1 MONTH 3) GENERALISED WEAKNESS SINCE 1 MONTH HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN SHE HAD SHORTNESS OF BREATH WHICH RELIEVED ON TAKING REST ,NO ORTHOPNEA, NO PND. -C/O GENERALISED WEAKNESS SINCE 1MONTH ,13 DAYS BACK SHE WENT TO THE SURYAPET HOSPITAL ,THERE THEY DID HAEMOGRAM AND DIAGNOSED AS ANEMIA, AT THAT TIME HER HB WAS 3 GM/DL. -C/O FEVER SINCE 1 MONTH, INTERMITTENT IN NATURE.10 DAYS BACK SHE HAD HIGH GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED ON TAKING MEDICATION. -C/O COUGH SINCE 2 DAYS ,WHICH IS  PRODUCTIVE, YELLOWISH IN COLOUR AND NON FOUL SMELLING -H/O HEAVY BLEEDING LAST MONTH (LASTED FOR 11 DAYS(1ST 6 DAYS HEAVY BLEEDING THEN NEXT 2 DAYS BLEEDING, STOPPED THEN AGAIN 5 DAYS BLEEDING OCCURED) -NO H/O BLOOD IN THE STOOLS, HEM

  This is an 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. Patient came to OPD with chief complaints of pain abdomen since 4 days HOPI :   Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive