GM Case 9 13/09/2023 -58 year female with headache since 2 months

Hi I am P.Kathyayani, 5th sem medical student. This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatever.

CHIEF COMPLAINTS:

58 year old female, resident of Suryapet, daily wage laborer by occupation came to OPD with chief complaints of headache since 2 months.

HISTORY OF PRESENT ILLNESS:

H/o trauma to head 2 months ago

Patient was apparently asymptomatic 2 months ago then she had a h/o of taruma with lacerations over parietal region for which suturing was done,from then she had h/o of headache which  was throbbing pain, continuous,non-radiating accompanied by burning sensation of eye and lacrimation of eyes.

No h/o blurring of vision

No h/o nausea and vomiting 

No h/o seizures, diplopia 

DAILY ROUTINE: 

Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.

After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.

PAST HISTORY:

Similar complaints of headache in the past - gives h/o fall 

C/o left foot pain with pus discharge - h/o thron prick

C/o left sided lower back pain non

radiating since 8 years gives h/o fall.

Not k/c/o DM,TB,Asthma,CAD

SURGICAL HISTORY: Hysterectomy was done 15 years ago

PERSONAL HISTORY:

- married

-normal appetite 

- mixed diet

- regular bowels

- normal micturition 

- no known allergies 

- addictions: toddy drinker once in 6 months.

FAMILY HISTORY: not significant 

DRUG HISTORY:

TAB.Calcium carbonate and vit D3

TAB.NAXOS-D 500mg

TAB.Cefredrox-CV

GENERAL EXAMINATION:

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time and space

- well built and adequately nourished

- no pallor 

- no icterus

- no cyanosis 

- no clubbing of fingers 

- no lymphadenopathy 

- no edema of feet

- no malnutrition 

- mild dehydration 

VITALS:

- Temperature: afebrile 

- Pulse: 76beats /min 

- RR: 20 cycles/min

- BP: 110/70 mm Hg

-SPO2:98%

SYSTEMIC EXAMINATION:

Respiratory System

- upper respiratory tract : oral cavity, nose & oropharynx appear normal

- chest is bilaterally symmetrical 

- respiratory movements appear equal on both sides and of thoracoabdominal type

- position of trachea : central

- vesicular breath sounds : present

-no wheeze 

Cardiovascular System:

Inspection :

- shape of chest : elliptical

- no engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

- no cardiac thrills 

Auscultation : 

- S1,S2 are heard

- no murmurs

Abdomen:

- shape: obese

- no tenderness

- no palpable mass

- no bruits

- no free fluid

- hernias orifices: normal

- liver: not palpable 

- spleen : not palpable

- bowel sounds:yes

- genitals: normal

- speculum examination : normal 

- P/R examination : normal

Central Nervous System:

- conscious 

- normal speech

- no neck stiffness

- no Kerning's sign

- cranial nerves: normal

- sensory : normal

- motor: normal

- reflexes: all present bilaterally

- finger nose in coordination: not seen 

- knee heel in coordination: not seen

- gait: normal

-Skin:Scar on parietal region

INVESTIGATIONS:

Hemogram

Bleeding and clotting time

Urine examination 

HIV 1/2Rapid Test 

HBsAg-Rapid 

Anti-HCV Antibodies -Rapid

USG

ECG

PROVISIONAL DIAGNOSIS:

Chronic headache secondary to post trauma USG of left foot showed 2mm hyperechoic foci noted in left plantar aspect,surgery was done foreign body is removed 

TREATMENT:

TAB.Paracetomol 40mg

TAB.HIFENAC-P

TAB.LIMCEE 500mg