Intern: Deepthi Thunga
PG- I: Dr. Durga Krishna
Faculty on call : Dr. Arjun
This is an online e log book to discuss our patient de-identified health data 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 evidence based input
This E blog 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 diagnosis and treatment plan.
A 36 year old female patient came with C
/O PAIN ABDOMEN SINCE 10 DAYS ON AND OFF ASOCIATED WITH ABDOMINAL DISTENTION SINCE 2 TO 3 DAYS LOW GRADE FEVER 10 DAYS AGO LASTED FOR 2 DAYS AND SUBSIDED SOB ON EXERTION ( GRADE II)
VOMITINGS SINCE 2 DAYS 2 TO 3 EPISODES PER DAY , FOOD AS CONTENT, NON PROJECTILE
H/O WEIGHT LOSS 10 KGS IN 3 MONTHS
DECREASED APPITITE SINCE 15 DAYS
K/C/O DM SINCE 15 YEARS AND ON MEDICATION TAB. GLIMI 1 MG AND TAB. METFORMIN 500 MG
K/C/O HTN SICE 15 YEARS AND ON MEDICATION TAB. ATENOLOL 50 MG OD
K/C/O PULMONARY TB 3 YEARS AGO AND USED ATT FOR 6 MONTHS
O/E:
TEMPRATURE: AFEBRILE
PR: 130 BPM
RR: 20 CPM
BP:140/90 MM HG
SPO2: 98 % AT RA
GRBS: 141 MG/dL
CVS: S1,S2 + ; NO MURMURS
RS: BAE +; NVBS+
P/A: SOFT AND SCAPHOID; NON TENDER
CNS: INTACT
Investigations:
TREATMENT
1. TAB. ATENOLOL 50 MG PO/OD
2. TAB. LASIX 40 MG PO/ BD
3. TAB. ALDACTONE 25 MG PO/ OD
4. TAB. GLIMIPIRIDE 1 MG PO/OD
5. TAB. METFORMIN 500 MG PO/OD
6. TAB. ATT 5 TAB PO/OD
7. TAB BENFOME PLUS PO/OD
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