58yr old male with headache since 3-4 years ..!?

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."

Unit 5 
Ward 

A 58 year old male, resident of bengal, farmer by occupation came to casuality yesterday night with c/o. headache in the occipital region since 3-4 years, intermittent, associated with photophobia and aggravated by loud sound. No h/ o nausea, vomitings.
C/o. waking up at night 3-4 times to use the washroom.
H/ o generalised weakness since 3-4 years
Twitching of the muscles at night while he sleeps since 3-4 years
Decreased sleep( disturbed sleep, used to sleep for 6-7 hours now decreased to 3-4 hours)
H/o Burning micturition, intermittent since 2 years. 

He is a k/c/ o Diabetes since 12 years and is on TAB. GLIMIPERIDE 2MG + TAB  METFORMIN 500MG OD.
He is k/c/o hypertension since 10-12 years and takes TAB. AMLODIPINE 5MG + ATENOLOL 50 MG OD. 

He is an occasional smoker and alcoholic. 

He takes mixed diet, appetite normal, sleep reduced, bowel and bladder habits regular. 

On examination
Pt is conscious, coherent and cooperative
Vitals
Temp: afebrile
PR: 72 bpm
BP: 130/70 mm hg
RR: 18 cpm
Spo2: 98% at room air
GRBS: 117 mg/ dl 

No signs of pallor, icterus, cyanosis, clubbing, edema, lymphadenopathy. 
Hyperpigmented plaque with raw areas and areas of depigmention noted over medial malleolus.

CVS: S1 S2 +
RS: BAE+, NVBS+
PER ABDOMEN: SOFT, NON TENDER, BOWEL SOUNDS +
CNS: NAD

INVESTIGATIONS:
1.HEMOGRAM: microcytic hypochromic anemia with thrombocytopenia
2.CUE: sugar +
3.RBS:208mg/dl

4.PLBS:260mgldl
5.HbA1c:6.9%
6.RFT:
7.LFT:
8.ECG
9.Chest xray PA view
10.USG abdomen

TREATMENT:
1.Tab AMLODIPINE 5MG +TAB. ATENELOL 50MG PO/OD
2.T. GLIMIPERIDE 2mg +T.METFORMIN 500MG PO/OD
3.T. ZINCOVIT PO/OD
4.BP,PR monitoring 4th hrly

DERMATOLOGY REFERRAL :i/v/o itchy lesion over left leg since 10yrs.
O/E:Hyperpigmented plaque with raw areas and areas of depigmention noted over medial malleolus(left foot)

Diagnosis:  LICHEN SIMPLEX CHRONICUS
Treatment suggested: 
1.BETNOVATE CREAM local application/OD×2 weeks
2.Tab.TECZINE 10mg/od x 2weeks

PSYCHIATRY REFERRAL :
Imp:1.MODERATE DEPRESSION
2.ALCOHOL HARMFUL USE
3.TOBACCO DEPENDENCE SYNDROME

Treatment suggested:
1. Pt counseling and psycho educated
2.sleep hygiene technique explained
3.Tab.NEXITO FORTE od @night x 15days
4.Syp.CYPON bd x 15days
5.NICOTEX GUMS 2MG bd/sos x 15days






DAY-2
SOAP NOTES:
Soap notes
S-
No headache
No fresh complaints
O-
Bp-130/80mmhg
Pr- 76bpm
Temp :98.5F
Rr:18cpm
Cvs:s1s2heard
Rs: BAE+
P/A: soft,non tender
P-
1.Tab AMLODIPINE 5MG +TAB. ATENELOL 50MG PO/OD
2.T. GLIMIPERIDE 2mg +T.METFORMIN 500MG PO/OD
3.T. ZINCOVIT PO/OD
4.BP,PR monitoring 4th hrly

DAY-3
Soap notes
S-
No headache
No fresh complaints
O-
Bp-130/70mmhg
Pr- 74bpm
Temp :98.6F
Rr:18cpm
Cvs:s1s2heard
Rs: BAE+
P/A: soft,non tender
P-
1.Tab AMLODIPINE 5MG +TAB. ATENELOL 50MG PO/OD
2.T. GLIMIPERIDE 2mg +T.METFORMIN 500MG PO/OD
3.T. ZINCOVIT PO/OD
4.BP,PR monitoring 4th hrly

DAY-4
Soap notes
S-
No headache
No fresh complaints
O-
Bp-130/70mmhg
Pr- 75bpm
Temp :98.6F
Rr:18cpm
Cvs:s1s2heard
Rs: BAE+
P/A: soft,non tender
P-
1.Tab AMLODIPINE 5MG +TAB. ATENELOL 50MG PO/OD
2.T. GLIMIPERIDE 2mg +T.METFORMIN 500MG PO/OD
3.T. ZINCOVIT PO/OD
4.BP,PR monitoring 4th hrly


DAY-5
SOAP notes
S-
No headache
No fresh complaints
O-
Bp-120/80mmhg
Pr- 76bpm
Temp :98.6F
Rr:18cpm
Cvs:s1s2heard
Rs: BAE+
P/A: soft,non tender

P-
1.Tab AMLODIPINE 5MG +TAB. ATENELOL 50MG PO/OD
2.T. GLIMIPERIDE 2mg +T.METFORMIN 500MG PO/OD
3.T. ZINCOVIT PO/OD
4.BP,PR monitoring 4th hrly

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