GENERAL MEDICINE CASE DISCUSSION
April 13, 2023
General medicine case discussion
E LOG MEDICINE CASE
13/04/2023
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 : Krishna Pranavi Yallambhotla
Roll no : 61
2020 Batch
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.
CASE DISCUSSION:
A 54 year old female patient farmer by occupation came to medical OPD with
CHIEF COMPLAINTS:
Vomiting since 2 years associated with headache, unconsciousness and neck pain.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 years ago.
Later she developed projectile vomiting since 2 years which increased in the past 6 months.
Frequency of vomiting was one per a month from 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 was succeeded by unconsciousness and syncope and 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.
PAST HISTORY:
History of trauma to head 6 years ago.
Treated with suture and medications.
No history of other comorbidities.
FAMILY HISTORY:
no significant family history
PERSONAL HISTORY:
Diet: mixed
Appetite:normal
Sleep: inadequate
Bowel: regular
Bladder: normal micturition
No known allergies
Addictions: occasional intake of palm wine
Surgical history : hysterectomy done 10 years ago
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
