A 77 year old woman with diminution of vision

 Welcome to my blog! I am Varshitha Kalidindi, a 4th year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.


I will be looking forward to some feedback and valuable inputs through the comments box provided below. 

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, diagnosis and treatment plan.

CASE:-

A 77 year old housewife came to the OPD with the complaint of diminution of vision in the right eye since 6 months.

HISTORY OF PRESENTING ILLNESS:-

The patient was apparently asymptomatic until 2 years ago, when she 




DAILY ROUTINE:-




PAST HISTORY:-





FAMILY HISTORY:-





TREATMENT HISTORY:-





PERSONAL HISTORY:-





MENSTRUAL HISTORY:-

Attained menopause    years ago



OBSTETRIC HISTORY:-






GENERAL EXAMINATION:-

The patient is conscious, coherent and cooperative.

The patient is         and well-nourished




Height:

Weight:

BMI:

VITALS(As of 3/12/2023,   pm):-

Temperature:

Blood pressure:

Pulse rate:

Respiratory rate:

EYE EXAMINATION:-





SKIN EXAMINATION:-

Silvery white plaque noted over the left foot

SYSTEMIC EXAMINATION:-

CNS:







CVS: S1 and S2 sounds heard, no murmurs

Respiratory system: NVBS+, BAE+

Per abdomen: Shape of abdomen is 

                       No palpable organs.


PROVISIONAL DIAGNOSIS:-

Right IMSC

+Palmoplantar Psoriasis + Intertrigo

INVESTIGATIONS:-










TREATMENT HISTORY:-








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