General Medicine Case Discussion

April 19 , 2023

 General medicine case discussion

E LOG MEDICINE CASE

19/04/2023

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 : Mamatha. N

Roll no : 65

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission:18/04/2023

A 60 year old female patient who is a housewife by occupation came to opd with 

Chief complaints : 

Of dizziness associated with one episode of vomiting two days back .

History of presenting illness :

The patient was asymptomatic 2 days back.  Suddenly she felt dizziness in the evening. No associating factors like headache, fever are seen. Dizziness is associated with one episode of vomiting which is sudden in onset and  was nonprojectile ,non bilious with food contents. 

Past history :

A known case of hypertension since 4 years. 

Right nephrectomy was done 2 months back. 

No history of DM, Epilepsy, Thyroid, TB. 

Family history : 

No significant family history. 

Personal history :

Sleep : Adequate

Appetite : Decreased 

Diet : Mixed Diet 

Bowel and Bladder movements : Regular 

Allergies : None 

Addictions : 6 months ago she used to consume betal leaf.  

General examination :

No consent for general examination.