General medicine E-Blog
Hi, I am N .Annmaria , 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 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 a diagnosis and treatment plan.
CHIEF COMPLAINT:
A 54 year old female patient farmer by occupation came to medical OPD with chief complaints of
Vomiting since 2 years
Associated with headache, unconsciousness and neck pain.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 years ago.
Projectile vomiting since 2 years which increased since 6 months.
Frequency of vomiting was one per one month for two years which increased to one per 15 days since 6 months.
Vomiting is non bilious, non blood stained, watery with food contents,
Vomiting is preceded by nausea, headache, and giddiness and succeeded by unconsciousness and syncope.
Also associated with sweating and giddiness and not associated with fever.
Headache was localised to frontal lobe, non radiating and throbbing type. It was not relieved by medication and postural changes. It was not associated with photophobia and phonophobia.
She has neck pain which is bilateral, non radiating, not relieved by medication and postural changes, It was not associated with neck stiffness.
HISTORY OF PAST ILLNESS
History of trauma to head 6 years ago.
Treated with suture and medications.
History of hysterectomy 10 years ago due to tumour.
No history of other comorbidities.
FAMILY HISTORY
no significant family history
PERSONAL HISTORY
Married
occupation: farming
Mixed diet
Normal appetite
Inadequate sleep
Bowel and bladder movements regular
No known allergies
Addictions: occasional intake of palm wine
PHYSICAL EXAMINATION
GENERAL EXAMINATION
conscious and coherent
pallor absent
No icterus
No lymphedemopathy
No clubbing of fingers
Edema absent
No malnutrition
No dehydration
VITALS
temperature: 98.4°F
Pulse rate: 74 bpm
Respiration: 20/min
BP: 130/70
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