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
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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:
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
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
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