SahithiReddy158

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 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-centred 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 16 year old female studying in 10th class came to OPD with Timeline CHIEF COMPLAINTS OF: Fever since 10 days Shortness of breath since 1 week Constipation since 4-5 days Vomiting

55 yr old female who is a home maker came to opd with chief complaints of  Fever since 4 days HISTORY OF PRESENTING ILLNESS : Patient was apparently asymptomatic 4 days back then she developed fever which was high grade and continuous type,  didn't releive on medication.  H/o 1 episode of vomiting 4 days back contents being food particles,  non bilious,  non projectile.   H/o giddiness & fall 3 days ago.   No c/o SOB,  pedal edema  No c/o melena,  hemetemesis  K/c/o HTN  since 2 yrs on medication ( Tab,. ATENELOL 50mg PO / OD )  PAST HISTORY: She went to a local doctor 3 yrs back i/v/o generalised itching for which she was prescribed Tab. Prednisolone 10 mg PO/OD & was using it since then  Not k/c/o DM,  asthma, thyroid disorders , epilepsy  ON EXAMINATION: Patient is conscious , coherent and co-operative Vitals: Temp: 99.4 f HR: 78 bpm RR : 20cpm BP : 110/80 mm hg Spo2: 99 @ RA SYSTEMIC EXAMINATION: CVS : S1 S2 + .  RS : BAE + NVBS +  PA: soft, Non tender    CNS : NAD  I

60 year old female came to OPD with chief complaints of  Acute retention of urine since 5 days HISTORY OF PRESENTING ILLNESS: The patient was apparently asymptomatic 20 days back .she visited her younger sister house for attending some function there she had a fever which was low grade associated with chills and rigor.which was on and off.increased during night time. Associated with cold she visited local rmp fever was relieved on medication .after 10 days she had decreased urine out put and not passed stools for 2 days and had 1 syncope attack. She felt on the ground which was observed by her relatives * Suprapubic bulge was noted and she had pain over suprapubic region. her son taken her to local hospital for examination and Foley's catheter was kept and she passed approximately about 1 litre of urine . * Their they told that infection is there and referred to our hospital. No c/o chest pain, sob, palpitations PAST HISTORY: She is not a k/c/o diabetes, hypertension,asthma,tb, e

69 year old male came to OPD with chief complaints of  Bilateral pedal edema present since 15 days Burning micturation since 15days Increased frequency of micturition (10-15times per day ) and urgency  Nocturia 5-6 times  Itching all over the body since 7 days HISTORY OF PRESENTING ILLNESS:  Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and burning micturition . There is increased frequency of urination i.e; 10 to 15times per day and nocturia with 5 to 6 times at night. PAST HISTORY: Patient had chronic eczema over right lower limb with uremic pruritis and generalised xerosis for which he was using liquid parafin and diphenaramine hydrochloride tablets. He was not a known case of DM,HTN and asthma PERSONAL HISTORY: Diet : Mixed diet Sleep : disturbed because of nocturia with a frequency of 5 to 6 times Bowel movements are regular Bladder movements had increased frequency of micturition and urgency wi

55 year old male painter by occupation came to casualty with cheif complaints of   1.Giddiness since 2 days 2.lethargy since 1 day Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom,he fell on his knees,no LOC,No involuntary movements of UL/LL Taken to outside hospital found out to be having BP-250/120mm of hg, antihypertensives were given From 1 day pt is lethargic, decreased responsiveness, brought to our hospital for further evaluation. On presentation to casualty BP:180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg PAST HISTORY: K/C/O HTN since 2 years and on irregular medication,Not a K/C/O DM, Bronchial asthma,CAD FAMILY HISTORY: No family history of HTN, DM, bronchial asthma, epilepsy GENERAL EXAMINATION: Patient is conscious,coherent, cooperative,Oriented to time,place and person No signs of pallor,icterus,cyanosis,lymphadenopathy&pedal edema VITALS: Temp:- 98.3 F BP:- 180/120 mmhg RR