60F with left flank pain since 12days and fever since 10 days

-

 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.



Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 A 60 year old female presented to Casuality with, 


CHIEF COMPLAINTS:


Left Flank pain since 12 days


Fever since 10days


Burning micturition since 10days


Increased frequency of micturition since 10days


Vomitings since 2days


HISTORY OF PRESENTING ILLNESS:


Patient was apparently asymptomatic 12days ago, she then developed pain in Left flank since 12days.


-Insidious and gradually progressive, radiating


 from left flank to groin


-Spasmodic and pricking type of pain


Fever since 10days


-High grade


-Associated with chills and rigors


-Relieved with medication


Burning micturition since 10days


-Increased frequency of micturition since 10days


Vomitings since 2days


-Content food material


-Non bilious


-Non projectile


-Not blood stained


DAILY ROUTINE: 


Patient is a Fruit seller by occupation. 


She wakes up at 6am, has breakfast at 6:30am, goes to work at 10am, has lunch around 1-2pm, comes back home at 6 pm, has dinner at 9pm and goes to sleep around 10-11pm.


Since 10days she hasn't been able to go to work due to Left flank pain and body pains. 


PAST HISTORY:


Patient is a known case of Diabetes Mellitus type 2 since 25years , on Tab. Glimi -M2 PO/OD


Patient is a known case of Hypertension since 25years, on Tab.Amlong 5mg PO/OD


History of Hysterectomy 23years ago


PERSONAL HISTORY:


Patient complains of body pains and decreased appetite since 10days


Bowel movements are normal


History of pruritis seasonal(summer) 


FAMILY HISTORY:


No similar complaints in the family members

GENERAL EXAMINATION

Pallor negative

No signs of icterus,cyanosis, clubbing, lymphadenopathy and pedal edema

.SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 S2 heard , no cardiac murmurs.

RESPIRATORY SYSTEM

Position of trachea is central and breath sounds are vesicular.

ABDOMEN 

Shape of abdomen Scaphoid, no tenderness, palpable mass, free fluid. 

Bowel sounds heard

CNS 

Patient is coherent, cohesive and conscious.

No neck stiffness

Reflexes are normal 

SKIN

Cutaneous examination:

Multiple polysized annular scaly hyperpigmented plaques with erythematous margings noted over groin,buttocks, thigh, left waist, lower back, lower abdomen, both axilla and face. Clavus was observed on 

his right leg.


PROVISIONAL DIAGNOSIS 

Tinea corporis ET cruris.

VITALS

PR: 76bpm

Bp:120/80 mmhg

RR: 18cpm

SpO2 : 98% ROOM AIR 

GRBS: 109mg/dl

Height: 5.5 feet 

Weight : 69kgs

Temparatu

re: 98.6°F


Comments

Post a Comment

Popular posts from this blog

Pre final OSCE and Learning points

-
Image
  The case allotted to me one day before the exam is presented in the following log which can be found here https://126singareddymanasa.blogspot.com/2023/12/a-65-year-old-male-with-dka-with.html OSCE 1) Can diabetes cause Fatty liver, if yes how?      Yes, Diabetes can cause fatty liver.  Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in type 2 diabetes mellitus.  The pathogenesis of NAFLD is not yet fully understood, but insulin resistance appears to be a critical contributing factor with obesity as the most common cause of the insulin resistant. As body fat stores expand with  excess calories and progressive obesity, alterations in lipid metabolism along with inflammation in adipose tissue and ectopic sites of fat deposition lead to insulin resistance. Insulin resistance leads to increased its accumulation in body. This excess insulin increases lipolysis and increases the production of free fatty acids. The surplus amount of fatty acids cause an excess production of tr
Read more

A 65 year old male with DKA with community and acquired pneumonia and pre renal AKI

-
Image
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. Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references   A 65 year old male was brought to casualty with CHIEF COMPLAINTS Fever since 4 days Breathlessness since 1 day HISTORY OF PRESENTING ILLNESS   Patient was apparently asymptomatic 10 days back when he developed cold and cough with expectoration which is greenish and mucoid. Now the expectoration has de
Read more

General medicine - Formative assessment

-
Online bimonthly assignment Singareddy Manasa 3rd Semester Roll no. - 126          I have been given the following cases to solve in an attmept 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 diagnosis and treatment plans and to give review on the answer of the respective cases . This is the link of the questions asked regarding the cases   http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Question 1 : 1) PULMONOLOGY Case :  https://anuragreddy72.blogspot.com/2021/05/online-blended-bimonthly-assignment.html It is a case of  A 55 year old female patient, with the chief complaints of shortness of breath, pedal edema and facial puffiness. After going through the history of patient, doing all required examinations and investigations, the provisional diagnosis is given as Acute exacerbation of COPD associat
Read more