general medicine

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 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-centred online learning portfolio and your valuable inputs on the 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.
     


A 50 year old female patient came to hospital with the complaint of chest pain since 2 days ,burning micturition since 9 months and has tingling sensation in both upper and lower limbs since 1 year. Neck pain,  headache since the last 1 year and backache, knee pain since 1 year.


HISTORY OF PRESENTING ILLNESS: Patient is apparently asymptomatic 2 days back then had chest pain ( pricking type) on walking. She has burning micturition since 12 months and tingling sensation in both upper and lower limbs. Neck pain, knee pain since 1 year and has decreased appetite since 7 months. 

HISTORY OF PAST ILLNESS:
no h/o HTN
no h/o DM
no h/o TB
no h/o epilepsy
no h/o  asthma
no h/o CAD 

PERSONAL HISTORY:
Married
occupation- labourer
Mixed diet
no known allergies
Habits-  toddy- 2 glasses daily since 40 years 

FAMILY HISTORY:
no significant family history 

GENERAL EXAMINATION:
pallor - no
cyanosis- no
clubbing of fingers- no
edema of feet -no 

Temperature - afebrile 
BP- 140/90
spo2- 98%
pr-86bpm


Systemic examination:
CVS -S1S2+
P/A- soft non tender 
CNS - NAD 

Investigations 
 diagnosis-  cervical spondylosis


Treatment:
1. T amytriptilline-10mg 
2. T naproxen- 250 mgs po/sos( only during attack)
3.T ultracet orally twice daily  5 days
4. T B Plex forte orally at 2 pm

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