GENERAL MEDICINE ELOG-02 AUGUST 07,2021

Divya Polagoni
Roll No:01
Old batch
3rd semester

Under the guidance of Dr.Manasa (intern)

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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 a diagnosis and treatment plan. 

CASE SCENARIO

A 21 year female came to causality with chief complaints of headache since 2 days, radiating to neck with vomiting and nausea

HISTORY OF PRESENT ILLNESS

*H/0 headache since 2 days radiating to left side of neck with episode of vomiting Non bilious with food particles, Non projectile with nausea since 2 days 

*H/o similar complaints in past-gets relief within few minutes without any medication 

*No h/o photophobia, phonophobia. 

* No h/o diarrhoea, fever, giddiness, abdominal pain 

* No h/o diplopia, blurring of vision 

*No h/o trauma 

HISTORY OF PAST ILLNESS 

*N/K/C/O- HTN/DM-2/TB/epilepsy/CVA/CAD 

TREATMENT HISTORY 

* No h/o diabetes, hypertension, asthma, tuberculosis,CAD, antibiotics. 

PERSONAL HISTORY 

*Normal appetite

*Non vegetarian

*Bowels regular

*Micturition- normal

*No known allergies

* No drug use

FAMILY HISTORY   

* No h/o similar complaints in the family 

MENSTRUAL HISTORY   

*Menstrual cycle- Normal    

GENERAL EXAMINATION    

*No-pallor/Icterus/cyanosis/clubbing/oedema/malnutrition/lymphadenopathy/dehydration 

*Temperature-98.7°F

*Pulse rate- 72/min 

*Respiration rate-20/min 

*BP- 120/80mm/hg 

*SPO2-100% 

*GRBS-109mg%  

SYSTEMIC EXAMINATION 

Cvs:-  

*No Thrills

*Cardiac Sounds - S1, S2 +

*No cardiac murmurs 

RESPIRATORY SYSTEM     

*Dyspnoea - No

*No Wheezing

*Position of Trachea - Central

*Vesicular sounds  

ABDOMEN   

*Shape - scaphoid

*No tenderness, palpable mass, No free fluid, No bruits 

*No bowel sounds

*Hernial Orifices - Normal

*Liver, Spleen - Not palpable

*Genitals, speculum examination, PV examination, P/R examination - Normal

CENTRAL NERVOUS SYSTEM         

*Level of consciousness - conscious

*Speech - Normal

*No signs of Meningeal Irritation

*Cranial nerves - Normal

*No motor or sensory deficit

*Glassgow scale -15/15

*GAIT, MUSCULO SKELETAL SYSTEM, SKIN, EXAMINATION OF BREAST, ENT, TEETH AND ORAL CAVITY, HEAD AND NECK - NORMAL

PROVISIONAL DIAGNOSIS 

*HEADACHE

TREATMENT  

*TAB- DOLO 650 mg 

*TAB- NAPROXEN 500 mg


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