General medicine case discussion

B.Varshitha 
8th semester 
Roll no.21
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.


A 28 year old female patient resident of Kathangur came to the hospital with cheif complaints of headache since 2months

History of present illness 
Patient was apparently asymptomatic 2months back then he developed headache over frontal region insidious in onset and gradually progressive dull aching type lasting for 2 -3hours aggravated on stress, overthinking, emotional disturbances and relieved on medication
Headache is associated with dragging type of pain in neck ,blurring of vision and retroorbital pain
History of fever is present 15days back which is on and off relieved on medications and 3days back fever developed again 
H/O nasal block on left side
H/O of pain in left half of lower jaw
No H/O nausea and vomiting 
No H/O joint pains and muscle ache 
No H/O photophobia, phonophobia
No H/O cold and post nasal discharge 



 History of past illness 
N/K/C/O HTN, Diabetes,epilepsy,TB,asthma
History of Tonsillectomy 6 years back 
No H/O similar complaints in the past


Personal history 

• Diet : mixed
• Appetite: normal 
• Sleep : adequate 
• Bowel habits: normal 
• Bladder habits : normal 
No Addictions 

Menstrual history 
Irregular cycles

Family history 
NO H/O HTN, Diabetes,epilepsy,TB,asthma

Local examination 
Nose examination 
Nasal septal deviation on left side
Oral examination 
Caries in left molar of lower jaw
Periapical abscess is present 

Physical examination 

General examination 
Patient conscious coherent and well oriented to place and time 
• Pallor is present 
• No Icterus is present 
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished

Vitals
Temperature: Afebrile 
Pulse rate: 76/min
BP: 100/70mm of Hg
RR:16cycles per min


SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

No Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN

No palpable mass
No free fluid 
No briuts
No palpable spleen and liver


CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness
Sensory system- Normal
Motor system- normal

Provisional diagnosis: 

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