58yr old female with chronic headache post trauma and foreign body in left foot

13 sep 2023 
Hi, I am P.Durga Bhavani 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.”
Chief complaints
58yr old female resident of suryapet daily wage labour by occupation came to OPD with 
c/o -headache since 2 months
       -left foot pain
       -left side lower back pain

History of presenting illnesses 
Patient was apparently asymptomatic 2 month ago then she had h/o of trauma with laceration  over parietal region for which suturing was done from then she had h/o headache - throbbing pain continuous nonradiating accompanied with burning sensation in eyes,lacrimation of eye
C/o left foot pain-h/o thorn pick with discharge
C/o left sided lower back pain-h/o of fall 8 yrs ago ,pain is nonradiating   
No h/o chest pain,SOB,cough,cold,fever
No h/o sweating, palpitations, orthopnea
No h/o loose stools,nausea,vomiting
No h/o burning micturation,decreased urine output
No h/o loss of appetite, insomnia

Daily routine
Before she was sick,she used to wake up at 6am evey morning ,eat breakfast of rice and vegetables, complete her daily chores and leave for work by 9 am .She is a daily wage labroer by occupation and used to pack lunch which was same as her breakfast .She used to reach home by
7-8 pm after which she would prepare dinner and sleep by 11pm.
After she got sick,she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past history
Not a k/c/o DM/HTN/CAD/Thyroid/TB
 She had left hand fracture
Surgical history -she had hysterectomy 15 yrs ago 
Drug history :
Tab:cefpodoxime proxetil &      potassium clavulanate-500mg
  Tab:Naproxen sodium & domperidone  500mg
Tab:calcium carbonate & vit d3
Personal history
-married
- normal appetite 
- mixed diet
- regular bowel and bladder movement 
- no known allergies 
- addictions:toddy drinker once in 6 months

Family history -not significant

General examination

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- pallor present 
- no icterus
- no cyanosis 
- clubbing of fingers present
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- mild dehydration 
Vitals
-Afebrile
- Pulse: 76 beats/min
- RR: 20 cycles/min
- BP: 110/70 mm Hg

Systemic Examination

Cardiovascular System

Inspection 

- shape of chest : elliptical
- no engorged veins, scars, visible pulsations

Palpation 

-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills 

Auscultation 

- S1,S2 are heard
- no murmurs

Respiratory System

- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical 
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present

Abdomen
- shape: obese
- no tenderness
- no palpable mass
- no bruits
- no free fluids
- hernias orifices: normal
- liver: not palpable 
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination :normal
- P/R examination:normal

Central nervous system
-levels of consciousness: conscious
-speech:normal
-signs of meningial irritation :
 no neck stiffness
 no kernings sign
-cranial nerves: normal
-sensory system:normal
-Glasgow scales:15/15
-reflexes: all present bilaterally
- finger nose in coordination: not seen 
- knee heel in coordination: not seen
- gait: normal 
-scar on parietal region
L/E inspection
0.5×0.5mm ulcer noted over sole of right foot
Margin-irregular
Edges-sloppy
Floor covered granulomatous
Surrounding skin-normal
No active discharge
Palpation- all inspectory findings                                    confirmed
                 - tenderness present
                  -no local rise in temperature
                  -base is underlying muscle

     
Investigations 
Provisional diagnosis-chronic headache secondary to post trauma 
USG of left foot showed 2mm hyperchoic foci noted in left plantar aspect 
Treatment
Surgical referal taken and foreign body removed in aspetic conditions 
Tab:HIFENAC PO/BD
Tab:PAN 40MG PO/OD
Tab:LIMCE 500MG PO/OD

Popular posts from this blog

44yr male with CKD,CAD and hypertension

Image
44 yr male with CKD,CAD and hypertension 23/08/2022   Hi, I am P.Durga Bhavani , 3rd 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: A 44 yr old male came was admitted in the hospital on 2...
Read more

55 yr old male with SOB,dry cough, decreased urinary output

Image
September 24, 2023 Hi, I am P.Durga Bhavani, 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 patients 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 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.   CONSENT AND DE-IDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation an...
Read more

60 yr old male with dov in both eyes ,hypertension,bronchial asthma

Image
I am P.Durga Bhavani, 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 patients 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 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.   CONSENT AND DE-IDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation and privacy of the patien...
Read more