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.
Case presentation:
A 25 year old male patient who is a resident of Nalgonda and Daily wage labourer by occupation came with chief complaints of headache since 10 years.giddiness since 5 years.swaying while standing and walking since one year and speech disturbance since 1 year
History of present illness :
Patient was apparently asymptomatic 10 years back then he developed headache which was insidious in onset gradually progressive, diffuse type, associated with giddiness and was prescribed medications and spects by a local doctor and was free from symptoms for 2years.Later he developed similar complaints for which he opted for herbal medications with no improvement.
H/O trauma 3years back with loss of consciousness,no seizures, vomiting and no ENT bleeds.
He had multiple episodes of similar complaints in the past due to non compliance of treatment.
He had increased giddiness , headache swaying while standing and walking and speech disturbance since one year.
No blurring of vision, involuntary movements, diplopia, tinnitus, photophobia and phonophobia
Past history :
Not a k/c/o HTN, DM,TB,Asthma,Epilepsy, CAD.
Personal history :
Normal appetite, with mixed diet ,bowel and bladder movements regular and adequate sleep.
General examination :
Patient is conscious, coherent and co-operative
No signs of pallor, icterus, cyanosis, clubbing,lymphadenopathy and edema.
Vitals:
Temperature - 98.6F
Pulse 90bpm regular in rate and rhythm
RR - 20cpm
BP - 130/90 mm Hg recorded in right arm supine position.
