A 25 year old female with headache
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:
A 25 year old female came to opd with chief complaints of headache since 4days.
Nausea and vomiting since 2days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4days back then
She developed headache since 4days which is sudden in onset and progressive in nature and diffuse ,non radiating not associated with photophobia and phonophobia .no aggrevating and relieving factors.
She also developed Nausea and vomiting since 2days 3 episodes of vomiting which is non bilious,non projectile in nature food particles as content and aggravated after intake of food and relieved with medication, no h/o blood in vomitings
No h/o burning micturition, shortness of breath, orthopnea.
No h/o pain abdomen and tenderness.
PAST HISTORY:
N/K/C/O DM,HTN,TB,Asthma, Epilepsy.
H/O Tubectomy done 5yrs ago.
No H/O any blood transfusions done.
FAMILY HISTORY: Not significant.
PERSONAL HISTORY:
Diet:Mixed
Appetite: Normal
Sleep: adequate
Bowel and bladder movements:regular
No addictions.
GENERAL EXAMINATION:
Patient is conscious, cooperative, well oriented to time ,place and person. Moderately built and moderately nourished.
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.
VITALS
TEMP:Afebrile
BP:110/80mmHg
PR:80bpm
RR:15cpm
SYSTEMIC EXAMINATION:
•Cardiovascular system:S1,S2 heard, no murmurs
•Central nervous system:no focal neurological deficit
•Respiratory system:Trachea central, bilateral air entry present, normal vesicular breath sounds heard.
•Per abdomen examination:soft, non tender,no guarding and no rigidity and no organomegaly and bowel sounds are heard.
PROVISIONAL DIAGNOSIS:
HEADACHE UNDER EVALUATION.
INVESTIGATIONS:
•HEMOGRAM:
Hb:12.5gm/dl(13-17)
Total count:8,500cells/cumm(4000-10000)
Neutrophils:54%(40-80)
Lymphocytes:40%(20-40)
Eosinophils:1%(1-6)
Monocytes:5%(2-10)
PCV:35.6 vol%(40-50)
MCV:87.9fl(83-101)
MCH:30.9pg(27-32)
MCHC:35.1%(31.5-34.5)
RBC:4.05millions/cumm(4.5-5.5)
PLATELETS:2.74lakhs/cumm(1.5-4.1)
•COMPLETE URINE EXAMINATION:
Albumin:nil
Sugars:nil
Bile salts:nil
Bile pigments:nil
Pus cells:2-3
•RANDOM BLOOD SUGAR
94mg/dl(100-160)
•LIVER FUNCTION TESTS
Total bilirubin:1.02mg/dl(0-1)
Direct bilirubin:0.19mg/dl(0.0-0.2)
AST:33 IU/L(0-35)
ALT:29 IU/L(0-45)
ALP:252 IU/L(56-119)
Total protein:7.5gm/dl(6.4-8.3)
Albumin:3.75gm/dl(3.2-4.6)
Albumin/globulin ratio:1.00.
•RENAL FUNCTION TESTS:
S.UREA:21mg/dl(17-50)
S.CREATININE:0.6mg/dl(0.8-1.3)
S.URIC ACID:3
CALCIUM:10.4mmol/l
PHOSPHATE:3.9
SODIUM:135mEq/L(135-145)
POTASSIUM:4.4mEq/L(3.5-5.1)
CL:102mEq/L(98-107)
•SEROLOGY
HbsAg:negative
HIV: negative
HCV:negative
•USG
•ECG
DIAGNOSIS:
DIAGNOSIS:
Headache under evaluation
With Cholelithiasis.
TREATMENT:
1.TAB.NAPROXEN 250mg PO/BD
2.TAB.PAN 40mg PO/OD
3.TAB.ZOFER 4mg PO/BD
4.MONITER VITALS FOR EVERY 4TH HOURLY
Comments
Post a Comment