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 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-centred 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
● Hallticket no.1701006077
Timeline of An 82 year old female resident of nalgonda
● General Examination : at the time of admission
Patient was conscious,Oriented,Comfortable and Co-operative
Moderate Built and Nourishment
▪︎ afebrile
▪︎Palor: present
▪︎ Icterus-no
▪︎No Cyanosis-central/peripheral
▪︎ No Clubbing – bilateral/unilateral
▪︎ Pedal edema – bilateral
▪︎ No lymphadenopathy
▪︎ on examination
Patient is conscious,Oriented,Comfortable and Co-operative
Moderate Built and Nourishment
▪︎ afebrile
▪︎Palor: present
▪︎ Icterus-no
▪︎No Cyanosis-central/peripheral
▪︎ No Clubbing – bilateral/unilateral
▪︎ No Pedal edema – bilateral/unilateral
▪︎ No lymphadenopathy
●Vitals : at the time of admission
● VITAL SIGNS on examination
On day 2
PULSE: 55bpm ,irregularly irregular , condition of vessel wall- hard
BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position
RESPIRATORY RATE: 22cpm
TEMPERATURE: afebrile
▪︎ Shortness of breath at rest improving
On day 3
PULSE: 56bpm ,irregularly irregular , condition of vessel wall- hard
BLOOD PRESSURE: 130/80 mm of Hg measured in the Left Upper limb in the sitting position
RESPIRATORY RATE: 20cpm
TEMPERATURE: afebrile
▪︎Shortness of breath at rest improving
On day 4
PULSE: 60bpm ,irregularly irregular , condition of vessel wall- hard
BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position
RESPIRATORY RATE: 20cpm
TEMPERATURE: afebrile
▪︎Shortness of breath at rest improving
● SYSTEMIC EXAMINATION:
▪︎ CENTRAL NERVOUS SYSTEM
Higher mental functions :-
Patient is consious coherent and oriented
Language and speech are normal
Cranial nerves :- intact
Sensory system :-
Sensation right left
Touch felt felt
Pressure felt felt
Pain
-superficial felt felt
-deep felt felt
Proprioception
-joint position ✔ ✓
-joint movement ✔ ✓
Temperature felt felt
Vibration felt felt
Stereognosis ✔ ✓
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Gait :- Normal
Superficial and deep reflexes are elicited
No signs suggestive of cerebellar dysfunction
▪︎ CENTRAL NERVOUS SYSTEM
Higher mental functions :-
Patient is conscious ,coherent and cooperative
Language and speech are normal
Cranial nerves :- intact
Sensory system :-
Sensation right left
Touch felt felt
Pressure felt felt
Pain
-superficial felt felt
-deep felt felt
Proprioception
-joint position ✔ ✓
-joint movement ✔ ✓
Temperature felt felt
Vibration felt felt
Stereognosis ✔ ✓
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Gait :- Normal
Superficial and deep reflexes are elicited
No signs suggestive of cerebellar dysfunction
Ecg :
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