A 65 year old female housewife came with chief complaints of swelling all over the body.

General medicine E-Blog

Hi, I am N .Annmaria , 3rd Sem Medical Student.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 comment box is welcome.”

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. 

CHIEF COMPLAINT: 

A 65 year old female housewife from Adaguduru mandal came to General Medicine OPD with chief complaints of swelling in the legs, abdomen, hands and facial puffiness since 1 week.

HISTORY OF PRESENTING ILLNESS

She was apparently assymptomatic 1 week ago.
Then she developed sudden onset of generalized edema which was moderate in the beginning and gradually increased in the evening.
It was associated with dypsnoea on exertion.
It is not associated with pain, rise in temperature, nausea, vomiting and diarrhoea.
She was taken to Suryapet hospital where she received medication which showed slight improvement and she came here for complete recovery.
 
HISTORY OF PAST ILLNESS

She had history of non radiating lower back pain 5-6 years ago for which she was admitted to the hospital and recovered.
She was found to have partial hearing loss since childhood.
No h/o HTN, DM, Asthma, CAD, TB, Epilepsy

FAMILY HISTORY

She has no significant family history

PERSONAL HISTORY

Married
Mixed diet
Normal appetite 
Adequate sleep
Bowel and bladder movements regular
No burning micturition
No Allergies
No Addictions

GENERAL EXAMINATION

The patient was conscious
Well oriented with time, place and person
Cooperative and coherent
No Pallor 
Icterus present along with slight yellow discolouration of palms and nailbeds.
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No dehydration
Pitting type pedal edema - Grade 4 below knees
VITALS

PR: 76bpm
Temp: afebrile
BP: 110/70 mm of Hg
RR: 19 cycles per minute

LABORATORY INVESTIGATIONS

USG
2D Echo

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