5th june 2023
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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.
A 50year old female patient who resident of nalgonda presented to casualty with chief complaints of pain abdomen 7 days back and regurgitation of food .
History of presenting illness
Patient was apparently asymptomatic 15 years back then she had a episode of giddiness,was taken to hospital and diagnosed with Hypertension and on regular medication MET-XL25 mg.
Till 6 years back she is doing well developed Bilateral knee joint pain for which she was advised to take analgesics .
She started to take antacid medication since 4 years
1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .
Patient complaining of loss of appetite, regurgitation of food, difficulty in swallowing
5 days back
1 episode of vomiting bilious ,non projectile ,food as content
3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood
Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors
Pt presented to casualty on 3/6/23 evening
On checking her GRBS it was found to be HIGH.
URINE for ketone bodies found to be positive.
Past History:
Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.
Family History
Not significant
Personal History:
Pt is having loss of appetite, vowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No addictions.
Daily routine:
Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and used to stay at home
Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.
General Examination:
Pt is conscious, coherent,cooperative
Pallor present
no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.
Clinical images:
SYSTEMIC EXAMINATION:
Investigations:
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