thesis model 4 camp

 Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment.

Case sheet:

Chief Complaints:
A 55yrs old female, resident of  chandhupatla , house wife by occupation came to camp screening with chief complaints of  pain in raising the hand above the shoulder since 5 months 

History of presenting illness :
Patient was apparently asymptomatic 5months back then she developed restriction of movement of shoulder which is gradually progressing to a stage where she is unable to lift the hand above 45 degrees 
no h/o trauma 
no h/o fever chills cold cough 
no h/o abdominal pain 
Past history:
Patient is a known case of hypertension since 1years on unknown medication and dm-2 since 14 year on GLIMI -M2
N/K/C/O,  Asthma, TB,

allergic history : Not significant

Drug history: not significant

Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate 
Bowel and bladder movements : regular 
Addiction : occasional alcohilic{TODDY}, non  smoking





Family history: Insignificant 

General examination :
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema

Vitals:
Temperature : 98.6F
Pulse rate: 78bpm
Respiratory rate: 18cpm
BP: 110/80 mm Hg
SpO2: 98


Systemic examination :

Respiratory system :
Vesicular breath sounds heard
No additional breath sounds heard

Cardiovascular system :
S1 S2 heard
No murmurs

Abdomen:
Soft, non tender
OBESE

CNS:
No neurological deficits seen



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