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, graduall...
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 COM...
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 PU...
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