General Medicine Case Discussion

General Medicine Case Discussion

June 01, 2023
General medicine case discussion

E LOG MEDICINE CASE

01/06/2023

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 : U.Sri Vidya 

Roll no : 121

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.

CASE DISCUSSION

Date of admission: 26- 05-2023
A 79  year old female patient came to OPD with 
Chief Compliants -
-Lower back ache since 5 months.
-with complaints of burning sensation of both upper and lower limbs since 5 months.
- pain during defecation since 5 months.
- fever since 10 days.

History of presenting illness:
Patient was apparently asymptomatic 5 months back. Then she complained of lower back ache which was insidious in onset,gradually progressive ,aggravated on bending and is relieved on medication.

She developed burning sensation of both UL and LL since 5 months which is not associated with any tingling and numbness of the limbs.

She also complaints of burning micturition since 5-6 months, nocturia present and pain during defecation which is non blood stained.

Since 10 days she complaints of low grade fever which is not associated with chills and rigor,on and off with no cough and cold.

Past history:
No history of DM ,HTN , thyroid, epilepsy .

Family history:
No significant family history.

Personal history:
Appetite - Normal
Sleep - Adequate 
Bowel and bladder movements - Regular 
Allergies - None
Addictions - None

General Examination:
Conscious
Coherent
Coordinated
Well oriented to time,place and person
Poorly built
Moderately nourished.
Pallor -  absent 
Icterus - absent 
Cyanosis - absent 
Clubbing of fingers - absent 
Lymphadenopathy - absent 
Pedal edema - absent 

Vitals:
Respiratory rate -15cpm
Pulse- 77 bpm
Temperature - 98.2 f
Blood pressure - 130/100mmhg


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