A 46 year old female came with complaints of left lower backpain since 3 years
December 30, 2022
General medicine case discussion
E LOG MEDICINE CASE
30/12/2022
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.
Name: K. Supraja
Roll no : 60
2020 Batch
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 comeup with Diagnosis and Treatment plan.
Case presentation
A 46 year old female, labourer by occupation came with chief complaints of
Headache, ear itching, neckpain since 10 years under evaluation.
left lower back pain since 3 years.
associated with giddiness + , Insomnia +
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 10 years back. Then she developed headache radiating to neck associated with nausea and vomitings.
On consulting an ophthalmologist, she was given spectacles and medications with reduced her symptoms to some extent. She used medications for an year and stopped using spectacles since one year.
Since 5 months , she is having burning micturition accompanied by back pain at the left lumbar region. Pain was inscidious on onset. On consulting an RMP, she was given IV which didnot reslove the issue. Then she got a scan from private hospital which revealed renal cysts. She used medication for the above for 6 months. She often experiences pricking type of pain in the same region.
Back pain was non progressive, non radiating to left leg.
HISTORY OF PAST ILLNESS
No history of similar complaints in the past.
H/O tubectomy 19 years ago
H/O hysterectomy 14 years ago.
No history of DM, HTN, TB, Epilepsy, asthma
PERSONAL HISTORY
mixed diet
Inadequate sleep
Appetite normal
Burning micturiton
Bowel regular
Occasionally one glass of toddy
MENSTRUAL HISTORY
AOM :15 years
7/30 cycle
LMP :14 years ago
FAMILY HISTORY
no significant history
GENERAL EXAMINATION
Conscious coherent cooperative
Well oriented to time place person
Examined in sitting position
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema
Vitals:
Temperature 98 degree fahrenheit
BP 130/90 mm Hg
Pulse rate 100/min
GRBS 120mg%
SYSTEMIC EXAMINATION
CVS
S1 S2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
No dyspnea, no wheeze
Position of trachea - central
Vesicular breath sounds
ABDOMEN
shape of abdomen - scaphoid
No tenderness, no palpable mass
No organomegaly
Bowel sounds- heard
CENTRAL NERVOUS SYSTEM
Rhomberg sign -
slight swaying +
INVESTIGATIONS
Hemogram, USG- abdomen, CUE, 2D echo, chest Xray.
Left lower backpain under evaluation.
