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.
Chief complaints:
-generalised weakness since 5 months
- loss of appetite since 5 months
- hematuria since 2 days
- dizziness since 5 months
- sob ( grade 2-3) since 5 months
- fever since 1 week
History of presenting illness:
Patient was apparently asymptomatic 2 years back where she developed swelling of left lower limb first as with pain and then swelling progressed to whole body where she got admitted to Osmania and treated and swelling subsided and patient is doing fine .after 1 year of that event patient gradually developed generalised weakness, easy fatiguability, loss of appetite,weight loss, sob ( grade 2-3) not with cough, cold , palpitations,
She has fever which is intermittent, low grade not associated with chills and rigors
She also has Hematuria for which she went to local hospital where she found to have Anemia for which she was transfused 5 units of blood in a span of 20 days and was discharged.
She was doing fine.
Since 5 months patient is experiencing similar complaints and went to hospital where she was found to have Anemia and got transfused 2 units of blood and came here as they were unsatisfied with the treatment there
Past history:
Not a known case of HTN, DM 2 , CVA, CAD, TB , EPILEPSY ETC
She underwent hysterectomy surgery at the age 36 years after the third childbirth
PERSONAL HISTORY:
A 50 year old female ,mother of 3 children ( 2 sons and 1 daughter)
Farmer by occupation
Diet - mixed
Appetite- decreased since 1 year
Bowel and bladder - regular
Sleep- adequate
Allergies - No
Menstrual history -
Menarche - 13 years age
Past - A Regular cycle 5/30
Present - hysterectomy done at the age of 36 yrs
Daily routine
She wakes up at 5 o clock and does her daily activities and then she prepares for breakfast and have her breakfast at 7 o clock and then goes for work and at 12 o clock she haves her lunch near the field and in the evening she goes to home at 7 o clock and prepares for dinner and eats dinner and then goes to bed at 9-10 pm
After symptoms
She is not going to any work since 1 and half year she stays at home and takes rest .
General examination :
Patient is concious , coherent and cooperative well oriented to time place and person
Poorly built and poorly nourished
Patient was examined in a well lit room and after taking consent with adequate exposure .
Pallor - present
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