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 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 4...
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...
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