A 60 year old female , handloom weaver by occupation came with complaints of pedal edema since 3 months, SOB since 1 month.
January 3,2023
General medicine case discussion
E LOG MEDICINE CASE
3/1/2023
This is supraja of 3rd semeter. This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.
Name: K. Supraja
Roll no : 60
2020 Batch
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 comeup with Diagnosis and Treatment plan.
Case presentation:
A 60 year old female came to general medicine OPD with chief complaints of:
Swelling of both foot,legs,face since 3 months
Breathlessness since 3 days.
History of present illness:
Patient was apparently asymptomatic 3 months ago. Then developed bilateral pedal edema 3 months back, which progressed gradually upto the thighs. Also had facial fluffiness.
Later she gave history of shortness of breathe since 3 days. She had increased difficulty of breathing after intake of food.
Past History:
No history of similar complaints in the past.
k/c/o HTN since 10 years .
DM since 9 years.
k/c/o CKD since 4 years.
Surgical history:she has a history of hysterectomy 15 years back
She had right eye surgery .
Family History:
No significant family history
Personal History:
Mixed diet
Normal appetite
Inadequate sleep
No Burning micturition
Bowel- regular
No known allergies
No Addictions
Drug allergies:
No known drug allergies
Physical Examination:
General Examination:
Conscious, coherent and cooperative
Well oriented to time place and person
Normal gait
Examined in sitting position
Moderatley built
Moderately nourished
Pallor present
No icterus
No cyanosis
No clubbing of fingers
No Lymphadenopathy
Pedal edema present
Vitals:
Temperature :afebrile
Pulse Rate: 98 beats per minute
Respiratory rate: 32 times per minute
BP: 110/80
SpO2 : 87% at room temperature
Systemic Examination:
CVS
S1 S2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM
No dyspnea, no wheeze
Position of trachea - central
Vesicular breath sounds
ABDOMEN
shape of abdomen - scaphoid
No tenderness, no palpable mass
No organomegaly
Bowel sounds- heard
CNS:
Conscious
Speech- normal
Signs of meningeal irritation -
no neck stiffness
no kerming's sign
Cranial system - intact
Motor system - intact
Sensory system - intact
Cerebellar signs-
Finger nose- in coordination
Knee heel - in coordination
No facial assymetry, all reflexes are normal
Provisional Diagnosis:
CKD since 4 years
HTNsince 10 years
DM since 9 years
CVA since 5months
Investigations:
