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'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 come up with a diagnosis and treatment plan.
CASE HISTORY:
A 34 year old male ,manson by occupation came with the chief complaints of:
1.Blurring of vision Rights eye more than left eye since 3 years
2.slurring of speech since 1 year
3.bodypains since 1 year
HISTORY OF PRESENT ILLNESSES:
Patient was apparently asymptomatic ago,then he developed giddiness and fell during his work
This episode of blackout was not associated with nausea, vomiting, vertigo,tinnitus, earfullness.Then he was taken to a local hospital and was diagnosed with high blood pressure. Since then he had been using medication for hypertension
He developed slurring of speech 1 year ago which was progressive
Body pains since 1 year
PAST HISTORY:
He had repeated episodes of blackouts since he was diagnosed with hypertension
He is a known case of hypertension since 3 years
No history of diabetes, asthma, tuberculosis, epilepsy
TREATMENT HISTORY:
He has been taking treatment for hypertension for the past 3 years
He used spectacles for 3 months for blurring of vision
No history of past surgeries
PERSONAL HISTORY:
Appetite is normal
Mixed diet
Sleep is adequate
Bowel and bladder - normal
No allergies
He was an alcoholic and smoker for 10 years
He used to take 90ml alcohol per day ,
FAMILY HISTORY:
Both of his parents have hypertension
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative and well oriented to time and place
VITALS on admission:
BP: 270/140 mm hg
given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg
PR : 90bpm
RR: 18 cpm
All the peripheral pulses present
Ankle brachial index > 1.25
Renal bruit present
BP:
RT LT
UL 160/100 170/100
LL 200 200
SYSTEMIC EXAMINATION:
CVS‐ S1 S2 heard, no murmurs
RS‐ Normal vesicular breath sounds hears
P/A -
shape of abdomen- scaphoid
No tenderness, no palpable mass
Bruit is heard on right side of umbilicus
CNS EXAMINATION:
Patient is conscious,coherent and cooperative well oriented to time and place
Higher mental functions are intact
Slurred speech
Signs of meningeal irritation are absent
CRANIAL NERVES EXAMINATION:
1 ‐ sense of smell intact
2 - there is blurring of vision Right eye> left eye ,colour vision present
Visual acuity - right eye - PL,PR present, hand movements perceived, cannot count fingers
3,4,6- able to move eyes in all directions
Pupil size - 4mm B/L
direct light reflex- present
5- sensation over face is present
Motor- weakness of masseter, temporaralis,pterygoids
Reflexes-
Corneal reflex ‐ present
Conjunctival reflex- present
Jaw jerk -present
7-Nasolabial fold on right side is not prominent
Angle of mouth deviated to left side
There is preservation of eye closure
8- normal hearing, no tinnitus, vertigo
9,10- gag reflex present
Uvula deviated to right side
11- normal
12-no deviation of tongue
2)MOTOR SYSTEM :
Right Left
Bulk:
Inspection. N. N
Palpation. N. N
Tone:
UL. N. N
LL. N. N
Upper Limb:
Shoulder: Flexion 5/5. 5/5
Extension. 5/5. 5/5
Abduction: 5/5. 5/5
Adduction: 5/5. 5/5
Elbow:
Flexion (biceps) 5/5. 5/5
Extension (triceps) 5/5. 5/5
Lower Limb:
Ilio psoas. 5/5. 5/5
Gluteus max. 5/5 5/5
Adductor femoris. 5/5 5/5
Hamstrings. 5/5 5/5
Quadriceps. 5/5 5/5
Tibialis ant. 5/5 5/5
Tibialis post. 5/5. 5/5
Ex. Digitorum L. 5/5. 5/5
Fl. Digitorum L. 4/5. 4/5
Ex. Hallucis L. 4/5. 4/5
Deep tendon reflexes:
Biceps: +2 +2
Triceps: +1 +1
Supinator: +2 +2
Knee: +3 +3
Ankle: +3 +3
Plantar: extensor flexor
Right knee jerk
Left knee jerk
Ankle jerk
Sensory:
STT: Crude touch. + +
Pain. + +
Temp. + +
Post. Dorsal
Fine touch. present
Vibration. + +
Position. + +
CEREBELLUM:
Nystagmus is present in horizontal direction with fast component to left side
Finger nose test couldn't be performed because of blurring of vision
Swaying to sides while walking
Unable to walk in in a straight line on his own
Couldn't perform tandem gait
Dysdiadochokinesia
INVESTIGATIONS:
On 28/10/21
on fundoscopy there is grade IV hypertensive retinopathy
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. This is a case of an 82 year old man with pain in the neck, lower back, right knee and tingling sensation in his right arm. History of Presenting Illness: Patient was apparently asymptomatic 10 years ago until he developed shortness of breath of grade 2. It has been occurring intermittently over the past 10 years. No history of Orthopnea or pnd Until 5 years ago he says he had a relatively normal life and ran his own barber business for over 60 years. About 6 years ag
Hello and welcome! My name is Bhargavi Kantipudi and i am a medical student from india. One of the most transformative experiences for medical students is patient case based learning, which offers a unique perspective in real world medical scenarios. I would like to present a selection of medical cases that i have examined. CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT We began our clinical rotations in 2nd year and in our initial days of medicine postings, I remember going to the ward a few times. I can recall a few patients, an old women with dysphasia, a man with tremors and bradykinesi
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. This is a case of a 45 year old male, carpenter by occupation came to OPD with chief complaints of: 1. Constipation since 3 days 2. Pain in abdomen since 2days 3. Vomitings since 2 days. HISTORY OF PRESENTING I
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