GENERAL MEDICINE CASE DISCUSSION.

3 January 2023

General medicine case discussion

E LOG MEDICINE CASE

03/01/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

Name: Kondakindi Vrithika Reddy

Roll no : 59

2020 Batch

I''ve 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 comeup with Diagnosis and Treatment plan.

A 60 year old female who is a labourer by occupation came to GM OPD with chief complaints of fever since 5 days, body pains since 1 months, low back pain since 1 month. 

History of present illness: 

The patient was apparently asymptomatic 1 month back when she developed pricking type of lower back pain along with slight body pains. She had a slight increase in her body temperature and tiredness since 5 days. 

Past History:

Know case of Hypertension since 10 years. 

No history of DM, TB, EPILEPSY, CAD

Tubectomy was done 30 years back. 

Family History:

No significant family history. 

Personal History:

Appetite: normal

Diet: Mixed

Bladder habits: regular

Bowel moments: regular

Sleep: deprived 

Addictions: Nil

Known Allergies: nil 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: absent

Vitals:

Temperature: 97.2 degrees Celsius

Pulse rate: 76 beats per min

Respiratory rate: 16

BP: 130/90

SPO2: 96%

GRBS: 100mg% 

Systemic Examination:

A. CVS

1. S1 and S2 sounds heard
2. No audible mummers
3. No trills

B. Respiratory system:

1. Dyspnea: absent
2. Position of trachea: center
3. Normal vesicular breath sounds are heard
4. No wheezing. 

C. Per-abdomen:

1. Scaphoid shaped abdomen
2. No visible swellings 
3. No visible scars and injuries
4. No tenderness
5. No palpable mass 
6. Bowel sounds: not heard

D. CNS:

1. Conscious 
2. Speech- normal
3. Signs of meningeal irritation - Nil
4. No neck stiffness
5. No kerming's sign
6. Cranial system - intact 
7. Motor system - intact 
8. Sensory system - intact 
9. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

Provisional Diagnosis: 

Treatment: