37 Years old Male

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' 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."
I've 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. 

Cheif Complaints : 
37 years old Male Who is a Carpenter by Occupation came with Complaints of 
Rt.Ear Discharge Since 12 Years of age on & Off
Skin Lesion in Perianal Region since 2 Years
HOPI : Pt. was apparently asymptomatic Till 12 years of age after which he started having Ear discharge From Rt Ear which was Mucoid, Non Foul Smelling, Non Blood Stained & Intermittent in Rainy Season ( Last Episode 1 year Back ) associated with Decreasing Hearing in Rt.Ear.
Skin Lesion which is Single Well Defined Pedunculated Mass in Perianal Region which is Not associated with any Discharge
Past History : 
Not a Known Case HTN ; DM ; TB ; Asthama; Epilepsy ; CAD ; Thyroid disorders
Personal History : 
Mixed Diet 
Appetite - Good 
Sleep - Adequate 
Bowel & Bladder Regular 
Addictions : Occasional Alcohol Drinker 1-2 Times Per Month 

General Physicical Examination : 
Patient is conscious, coherent 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 

VITALS : 
Temp - 98.3 F
PR - 78 bpm
RR - 16 cpm
BP - 120/80 mm Hg
Spo2 - 98% @ room air

SYSTEMIC EXAMINATION :
CVS - S1S2 + No Murmers
RS - BAE+ ; NVBS + 
P/A - Soft, nontender
CNS - NFND
Investigations : 
ENT Referral :
Dermatology Referral : 
Treatment : 
TAB .AMOXY CLAV 650MG PO TID FOR 7 DAYS
TAB.FUDIC CREAM LA FOR 1WEEK
TAB.PCM 650mG PO SOS
Discharge Summary : 
Breif Course in the Hospital : 
37 years old Male Who is a Carpenter by Occupation came with Complaints of 
Rt.Ear Discharge Since 12 Years of age on & Off & Skin Lesion in Perianal Region since 2 Years. 
Vitals at the time of admission: 
Temp - 98.3 F
PR - 78 bpm
RR - 16 cpm
BP - 120/80 mm Hg
Spo2 - 98% @ room air

ENT Referral was taken in v/o ear discharge .They Advised for NO active Intervention. Dermatology Referral was Taken in V/O Skin Lesion. They Performed Exicision and sent for biopsy. Pt vitals are Stable at the time of discharge.
Advise at Discharge : 
TAB .AMOXY CLAV 650MG PO TID FOR 7 DAYS
TAB.FUDIC CREAM LA FOR 1WEEK
TAB.PCM 650mG PO SOS
Further Review : 
Review after 1 week for Suture Removal




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