This is 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 centred 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 diagnosis and treatment plan.
A 63 year old female, resident of chittiyala and a milkmaid by occupation came to the OPD with the chief complaints of
- Dryness of mouth and inability to swallow since 2 months
- Ear pain and ringing sensation in ears on and off since 2 months
- Pain in the right distal phalanges since 2 months
- History of dizziness since 10days
HISTORY OF PRESENTING ILLNESS
The patient had a stroke at 5 months of age after which she had deviation of angle of mouth for which she took herbal medication.
3 years back when she had a pain in the left lower limb which was associated with redness and swelling. This was attributed to a insect but . She was taken to the hospital and on evaluation she was diagnosed with diabetes.
She was given medication and is compliant with the medication till date. She gets her blood sugar monitored every 2 months.
She complains of difficulty in swallowing since 2 months. Initially it was associated with burning type of pain for which she went to the hospital and was diagnosed with acute pharygo-larygitis and glossitis.
She was prescribed medication for the same. The burning sensation in the mouth reduced but dysphagia remained the same.
15 days after this she complained of pain and ringing sensation in the right ear. Not associated with loss of hearing, discharge from the ear, fever. She was taken to the hospital and was prescribed medication. The pain reduced but tinnitus is intermittent in nature.
5 days after this episode she complains of pain and bluish discolouration of the right upper limb distal phalanges. The pain is of pricking type and is relieved on taking pain medication (unknown)
PERSONAL HISTORY
- Diet: mixed
- Appetite: Normal
- Bowel: normal
- Bladder : normal
- Sleep: disturbed
- Addictions: nil
- Allergies (food/drugs) : nil
GENERAL EXAMINATION
Patient is conscious, coherent and co-operative; well oriented to time, person, place.
Well built and well nourished.
Pallor present.
No icterus, clubbing, cyanosis, edema, generalised lymphadenopathy.
VITALS:
- PR: 90bpm
- BP: 110/70mmHg
- RR: 16cpm
- Temperature: Afebrile
Investigations:
RBS: 164 mg/dl
Se. Creatinine: 1.2 mg/dL
Se. Uric acid: 11.1 mg/dL
Blood urea: 41 mg/dL
Na: 138 mEq/L
K: 4.8 mEq/L
Cl: 101 mEq/L
LFT:
Db: 0.16 mg/dL
Tb: 0.57 mg/dL
AST: 64 IU/L
ALT: 57 IU/L
ALP: 204 IU/L
TP: 8.0 gm/dL
Albumin: 3.6 gm/dL
A/G ratio: 0.89
Provisional Diagnosis:
Critical limb ischaemia
Raynaud's phenomenon ?
Treatment plan:
1. Tab. NIFEDIPINE 10mg TID
2. IV FLUIDS 2 NS
3. Inj. ACTRAPID 10 units
(Morning- afternoon-night)
4. Tab. FOLITRAX 7.5mg once a week
Every Wednesday
5. Tab.FOLIC ACID 5mg once a week on Tuesday.
