A 48YR F COMPLAINS OF SWELLING IN THE NECK

LEARNER REPORT
"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 comments box.


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 TREATMENT PLAN.

A 48 YR F OLD PT. COMPLAINS OF SWELLING IN THE NECK SINCE 1YR
C/O HOARSENESS OF VOICE SINCE 6 MONTHS
C/O DIFFICULTY IN SWALLOWING SINCE 6 MONTHS
BURNING MICTURITION SINCE 1O DAYS AND ALSO HAS A HISTORY OF WT. LOSS SINCE 2 MONTHS . PT WAS APPARENTLY ASYMPTOMATIC 1 YR BACK THEN SHE OBSERVED "PEA" SIZED SWELLING IN THE NECK WHICH GRADUALLY INCREASED TO THE PRESENT SIZE

PAST HISTORY -
KNOWN CASE OF THYROID FOR A YEAR FOR WHICH SHE IS ON MEDICATION CARBIMAZOLE 25MCG
NOT A K/C/O HTN , DM

PERSONAL HISTORY -
DIET - MIXED
APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENT- REGULAR
SLEEP - ADEQUATE
ADDICTION

FAMILY HISTORY - NO SIGNIFICANT FAMILY HISTORY 
DRUG HISTORY - SHE IS ON MEDICATION FOR THYROID SINCE 1 YR. THAT IS CARBIMAZOLE 25MCG

GENERAL EXAMINATION-
PT. IS CONSCIOUS, COHERENT AND COOPERATIVE AND WELL ORIENTED TO HER SURROUNDINGS . SHE IS MODERATELY BUILT AND NOURISHED
NO PALLOR, NO ICTERUS , NO CLUBBING , NO CYANOSIS, NO LYMPHADENOPATHY

VITALS -
TEMP - AFEBRILE
BP - 120/80 MMHG
PR - 84 BPM
RR - 14 CPM
SPO2 - 98% @RA
SYSTEMIC EXAMINATION -
CVS - S1 , S2 HEARD
RS - BAE +
CNS - NAD
P/A -SOFT , NON TENDER







PROVISIONAL DIAGNOSIS -
HYPERTHYROIDISM

TREATMENT 
1) TAB . CARBIMAZOLE 10 MG PO / TID
2) TAB . PROPRANOLOL 40 MG PO/ BD

      
SOAP NOTES

S
SWELLING IN THE NECK 

O
VITALS 
TEMPERATURE - AFEBRILE
BP - 120/70 MM/HG
PR - 82 BPM
RR - 14CPM
RS - BAE +
CVS - S1 , S2 + 
CNS - NAD
SPO2 - 99@RA

A
GRAVES DISEASE

P
1) TAB . CARBIMAZOLE 10 MG PO / TID
2) TAB . PROPRANOLOL 40 MG PO/ TID
3) MONITOR VITALS






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