A 60 year old women resident of sathapuram, admitted in hospital with head spinning since 4 months
17 April, 2023
E LOG GENERAL MEDICINE
Hi, I am Nandini, 5th Sem Medical Student.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 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 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.
CHIEF COMPLAINTS:
Head spinning since 4 months.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 months ago.
From 3 months she had episodes of head spinning when she slept, sat, see up and down.
Had 3 episodes-1st she fell in the washroom.
2nd when she was getting up from bed.
3rd near office she fell suddenly and got conscious when she fell.
No pain
No headache
No nausea
No loss of vision
PAST HISTORY:
35 years ago hysterectomy.
30 years hypertension, regular medication
7 years ago bilateral knee replacement surgery due to loss of synovial fluid
3rd ago both eyes surgery
On 3rd episode (1month ago) she had wrist and leg fracture
FAMILY HISTORY:
No other history.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Bowels : regular
Bladder: regular
Sleep : adequate
Addictions:None
ALLERGIC HISTORY:
No known allergies.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Pallor is absent
Icterus is absent.
Clubbing fingers absent.
Cyanosis absent.
Lymphadenopathy absent.
Edema absent.
VITALS:
Temperature: Afebrile
