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.
75 year old daily wage worker resident of narapuram came to general medicine OPD with chief complaints of
swelling with pain above umbilicus since 5 years.
History of present illness
Patient was apparently asymptomatic 5 years ago then he noticed a swelling which is sudden in onset gradually progressive and painless initially which later became tender and painfull.
No aggravating or relieving factors for pain . The size of the swelling gradually increased . The current size of the swelling is about 3×4 cm.
No history of fever ,vomitings.
No history of cough .
No history of decreased urine out put and burning micturation.
Past history
Not a known case of diabetes , hypertension , epilepsy, asthma, tuberculosis
History of Extracorporeal shockwave lithotripsy for left renal calculi 3 years ago.
Personal history
Diet -mixed
Appetite -normal
Bowel and bladder movements -regular
Sleep -adequate
Addictions -occasionally alcohol
Daily route
Patient gets up daily at 4 am then he does he's eats roti and jawa for break fast goes to work by cycle and return home between 12 to 1pm he usually have his lunch between 12 30 to 1 pm which is mostly rice .Then in the evening he somes goes to his farm
His dinner is rice and curry most of the time
He goes to sleep 10 pm.
Family history
Not significant
General examination
Patient was conscious, coherent, cooperative and well oriented to time ,place and personPatient was moderately built and well nourished
No pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy
Vitals:
Temp - afebrile
RR - 16/min
Bp - 120 /70 mm of Hg
PR - 78 /min
Systemic examination:
CVS - S1 and S2 heard , no murmurs
CNS - Normal
RAS -
BAE +
Provisional diagnosis - epigastric hernia
Investigations
Final diagnosis:
Epigastric hernia with thrombocytopenia.
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