A 55 year old female resident of Suryapet , Homemaker came to OPD with Chief complaints of Left sided nasal blockage since 3 months, Left sided nasal discharge since one month

 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 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. 


A 55 year old female resident of Suryapet , Homemaker came to OPD with 

Chief complaints of

Left sided nasal blockage since 3 months

Left sided nasal discharge since one month

HOPI :

- The patient was apparently asymptomatic 3 months ago then she had a feeling of gradual obstruction of nose which was insidious in onset, which was increased during early morning, relieved on medication.

- Nasal discharge since 1 month from left nostril watery discharge, increased during morning and associated with paroxysmal sneezing, not blood stained, itching present sometimes.

- No H/O disturbances in smell

- No H/O epistaxis

- No H/O post nasal drip

- No H/O fever, headache


Past History:

- She had similar complaints in the past along with headache 1.5 years ago for which she underwent a posterior nasal surgery.

- She is a known case of HTN since 1.5 years but is not on medication

- N/K/C/O DM, TB , Asthma, Epilepsy, CAD, CVD, Thyroid disorders

- Treatment history:



Family History:

No similar complaints in family


Personal History:

Normal appetite, mixed diet, regular bowel and bladder movements, No allergies, No addictions


General Examination:

Patient is concious, coherent, cooperative

No pallor, icterus, clubbing, cyanosis, generalised lymphadenopathy, pedal edema





VITALS : 

Afebrile on touch

BP : 180/110 mmHg

Pulse : 82 bpm

RR : 16 cpm

SpO2 : 99% at room air


ENT examination:

On examination of nose:

Decreased fogging in the right side of nose

Anterior Rhinoscopy-

Caudal deviation from LEFT to RIGHT.

Anterior Deviated nasal septum to LEFT.

RIGHT Inferior turbinate hypertrophy present.

Mucosa is pale.


On examination of paranasal sinuses:

Frontal sinus tenderness present in left side


On examination of oral cavity and oropharynx:

Floor of the mouth looks normal

Dental caries present






Mild Anterior pillar congestion is present


On examination of Ear:


                                    Right               Left


Pinna                        Normal        Normal


External 

auditory canal        Normal        Normal


Tympanic

membrane             Normal           Normal

  

              Bilateral Tympanic membrane
Intact with normal cone of light.

SYSTEMIC EXAMINATION :

CVS -  

S1 , S2 heard 

No thrills and murmurs 


RESPIRATORY SYSTEM -

Trachea is central .

NVBS +

No adventitious sounds


ABDOMEN -

- Shape is Obese.

- No local rise of temperature, tenderness

- No organomegaly.

- Bowel sounds heard.


CNS - Higher mental functions intact

- No focal neurological deficit 


PROVISIONAL DIAGNOSIS:

Allergic Rhinitis

Came for General Medicine to control blood pressure 


INVESTIGATIONS:











Blood pressure on 06-12-2023

                      8:00PM-160/100 mm of hg

                     10:00PM-170/100 mm of hg


Blood pressure on 07-12-2023

                      12:00AM -160/100 mm of hg

                             2:00AM 160/100 mm of hg

                             4:00AM-160/100 mm of hg

                             6:00AM 160/90 mm of hg

                             8:00AM 160/110 mm of hg

                         

Treatment

1.) Tab . Cinod 10mg PO/OD

2.) Tab . Levocet 5mg PO/OD

3.) Blood pressure monitoring every 2nd hourly

4.) Tab . Telma 400mg PO/OD

5.) Tab . Amoxycillin 625mg PO/BD

6.) Tab . Allegra 120mg PO/OD


Investigations - 7/12/23




















Comments

Popular posts from this blog

Gen Medicine Case Study

A CASE OF 34 YEAR OLD MALE WITH CHEST TIGHTNESS AND SOB SINCE 4 DAYS