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 the following is my analysis of this patients problem:
the problems in order of priority i found are
the problems in order of priority i found are
CHIEF COMPLAINTS.
1) Frequent falls to the left. Left foot started giving out as well as hand. one fall down stairs sprained and broke ankle (last year) X-ray below. Poor stress response.
2) Swelling/ hair loss (head and eyelashes) Fatigue. Left jaw pain up into face.
3) Breathing difficulties.
4)intolerance from most foods, smoke.
5)Always less urination which increase when fasting.
6)Sleep was bad with 2-4 hours.
Obstetric history:
H/o of ectopic pregnancy.
Menstrual history:
Menarche -14 years
During mensus severe headache and abdominal pain.
Diagnosed with PCOD.
Family history:
Mother had fibromyalgia.
Father got heart attacks in early 40's
Drug history:
Allergic to sulfa drugs and antimalarials .
Surgical history:
LASIK done at 35 yrs is failed and diagnosed as dyslexic.
Personal history
Apple once a day
Sleep: inadequate
Bowel/ Bladder movements: regular
Appetite: reduced
No addictions
Investigations done
CBP shows she is anaemic
AST and ALT increased
Chest x ray shows left atrial enlargement
Further investigations
1.Ldh levels
2.bilirubin levels
3.peripheral blood smear
Treatment
She is on medication of Cimetidine
Control of triggers which cause swelling.
2.increased pain tolerance
Onset: since 4 years still present
Associated complaints
Multiple fractures
Fracture of knee
Probably diagnosis
Osteoarthritis
Pcod may be reason because of low estrogen
CIPA congenital intolerance to pain with anhydrosis
3.Sleep deprivation
Onset:
Since birth
Duration of sleep 2 to 4 hours
Probable causes are G6PD deficiency in this there will be impaired glycolysis so glycine is inhibitory NT
AMPDI deficiency
Treatment :she is on medication of serine and Cemitidine
4.Decreased frequency of urination probably due to G6PD deficiency in this there is reduced production of NADPH and lack of ions which cause decrease in urinary output and dark color urine.
Other causes could be physical trauma, infection
Investigations : urinary output
CUE
CT abdomen
Blood test
Treatment :increased fluid intake, diuretics, anti microbials in case of infection.