26 year female
August 27, 2022
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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.
Our 26yr old female patient came to the opd with chief complaints of
C/o headache since 8years
C/O B/L mastalgia since 2years
C/o SOB only on exertion
HOPI:
Patient was apparently asymptomatic 8 years ago and then developed headache which is diffuse in nature and associated with phonophobia and nausea.
No h/o vomitings,photophobia and patient was asymptomatic till 2years and since 2years she developed B/L dragging type of pain over breast which is insidious in onset, gradually progressive and not associated with any Swelling,redess,or discharge.
C/o sob only on exertion since 2years insidious in onset gradually progressive not associated with chest pain and palpitations.
Past history:
No similar complaints in the past
Not a k/c/o DM, HTN, TB,ASTHMA, EPILEPSY,CAD
Personal history:
Diet:mixed
Appetite: normal
Sleep: Adequate
Bowels:Regular
Micturition: Normal
No addictions
Family history:
Not significant
General examination:
Patient is c/c/c
Afebrile
BP:110/70mmhg
PR:86bpm
RR:14cpm
SpO2:98% at RA
Grbs:112mg/dl
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Local examination of breast:
Inspection: Bilateral breasts are equal in size ,no redness, Swelling and discharge in both the breasts on inspection
On Palpation:
Right breast -14*5mm sized, solid mass felt over central quadrant of right breast at 5'o clock to 6'o clock position
Left breast -8*4mm solid mass felt in central quadrant at 5'o clock position
All inspectory findings are confirmed on Palpation
No local rise of temperature
No breast tenderness
Systemic examination:
CVS:S1, S2 sounds heard
RS:BAE+, clear
P/A:Soft and non tender
CNS:NAD
Diagnosis:
Right and left fibroadenoma
B/L Duct ectasia
Treatment:
1)Tab.Hifenac P /PO/BD
2)EVION 600 mg /PO/OD
3) PRIME ROSE OIL for L/A
4)TAB.PAN 40mg/PO/OD
