Neha Tanyeem
March 12 2022
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
I have 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
A 54 yr old female came to casualty with a chief complaint of pain in the right side of the upper part of the thigh and hip line because of a sudden fall from the bed during the night.
HISTORY OF PRESENT ILLNESS
Patient fall down on his back suddenly from the bed during sleep 15 days back and had severe pain in the upper thigh and hip line area
Appetite is increased, not associated with nausea,vomitings, constipation, Bowel movements are regular.
Pain In the upper thigh and hip line ,cannot walk and stand, pain is relieved when lay down
HISTORY OF PAST ILLNESS
patient did not experience any kind of fall of before .Patient had a stroke 6 years back.Patient is diagnosed with a very high blood sugar level , and has BP also
PERSONAL HISTORY
Married
Occupation: farmer
Socioeconomic status: lower middle class
Appetite: increased
Diet: mixed
Bowel movements: regular
Alcohol history:
Doesn't drink alcohol and no habit of smoking
No known allergies
FAMILY HISTORY
Not significant
PHYSICAL EXAMINATION
No pallor ,icterus ,cyanosis, lymphadenopathy, clubbing ,oedema
VITALS
BP: 140 /90 mmHg
Temp: Normal
PR : 76 bpm
GRBS: 343 mg /dL
CVS : no thrills, murmurs
CNS : NAD
PROVISIONAL DIAGNOSIS
L GT FRACTURE
INVESTIGATIONS:
