General medicine case history 9

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.


A 30 year old female patient, resident of Parada, Hotel Server by occupation, came to our hospital with chief complaint of nasal pain.

Date of Admission:-26/03/2022

History of present illness:-
Patient was apparently asymptomatic 15 days back and developed pain in the nose which was sudden in onset, gradually progressive with no aggrevating and relieving factors.

History of past illness:-
Not a known case of diabetes, hypertension, tb, epilepsy.
Patient suffered from same problem 6 months ago and got her medical checkup done.

Personal history:-
Patient has normal eating habit with mixed diet.
Takes toddy occasionally.

Daily routine:-
Patient used to wake up at 4.00AM , goes to hotel at 7.00AM, takes breakfast in between 9.00AM-10.00AM. Then she continues her work, takes rice in between 2.00PM-3.00PM, dinner at 9.00PM and goes to bed by 10.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No pallor
No icterus
No clubbing
No Lymphadenopathy

Vitals:-
Temperature-99 F
Pulse rate-80 bpm
RR-20 cpm
BP-120/100 mmhg
SPO2-96% at room temperature
RBS-86mg/dl












Investigations:-
LFT
RFT
RBS
CBP
BLEEDING TIME AND CLOTTING TIME
CUE
MDCT SCAN-PNS(PLAIN)

Provisional diagnosis:-
Right Nasal polyposis

Treatment:-
Tab. Levocet 5mg H/S
Tab. Taxim-O 200mg × OD
Tab. Pan-D × OD
Tab. Metrogyl 40mg × TID
Flutirest nasal spray
Surgery suggested:-Nasal Polypectomy

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