48F with SLE since 7 months,TB 2013, vomiting and decreased appetite.

48F, SLE 7 Months,Hip TB 2013, vomiting and decreased appetite

September 23, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his /her guardian signed informed consent. Here we discuss our individual patients problems with collectors current best evident based input.This E blog also reflects my patient centered 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

Chief complaints : Patient had one episode of vomiting 6 days ago and has decreased appetite

History of presenting illness:

Patient was apparently asymptomatic 6 days back then came to opd with c/o single episode of vomiting 6 days ago which was non-projectile with food contents and patient also has decreased appetite.

Burning sensation in front of ear since 2 days and pain in mouth.

PAST HISTORY : similar complaint of vomiting 1 month ago which was relieved on medication.

k/c/o SLE since 7 months

has skin lesions since 7 months with burning sensation.

k/c/o psychosis and is recieving treatment.

k/c/o TB in 2013 in Rt hip joint.

no Diabetes Mellitus, thyroid, hypertension, asthma, CVA, trauma.

Past surgical history - hysterectomy 2 yrs ago.

PERSONAL HISTORY: mixed diet, decreased appetite, inadequate sleep, normal bowel and bladder movement, no addiction.

FAMILY HISTORY: nil significance

GENERAL EXAMINATION:

I have taken prior consent of patient.