.Case Scenario - A 55 year old woman from Nalgonda came to OPD on 3rd of June with chief complaints of:-pain abdomen , bilateral upper and lower limb swelling since 10 days and nausea since 1 week.

Hi, I am Ananya Aleti  a 5th 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. 

 CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Case Scenario - A  55 year old woman from Nalgonda came to OPD on 3rd of June with chief complaints of:-pain abdomen ,  bilateral upper and lower limb  swelling since 10 days and nausea since 1 week.

History of Presenting Illness- 

patient was apparently asymptomatic 10 days ago when she developed edema in bilateral upper and lower limbs and facial puffiness for which she consulted a local physician and was prescribed medication following which the symptoms subsidised but relapsed again 1 week ago.- since 1 week ago she has been experiencing nausea and dysphagia associated with 1 episode of vomiting after consumption of food which was non-projectile, non-bilious, having food contents.- 

h/o SOB Grade 4 since 6 months- 

h/o rashes on skin 1 month ago which subsidised spontaneously- 

h/o burning micturition -

 no h/o fever, diarrhoea, constipation, melena, bleeding, hematemesis.

Past History- 

k/c/o HTN since 5 years on regular medication- diabetic on examination - n/k/c/o tuberculosis, CAD, epilepsy, asthma, thyroid disorder- h/o abdominal surgery for mass 30 years ago- 

no h/o blood transfusions

Personal History-

 married-

 used to work as a housemaid before -

 mixed diet- reduced appetite- 

inadequate sleep- 

regular bowels- 

burning micturition-

 no known allergies- alcohol and tobacco addiction 35 years ago- analgesic abuse since 1 year

Family history 

- patients mother had breast cancer- patients brother had MI- 

no diabetes mellitus-

 no hypertension - 

no stroke-

 no tuberculosis 

- no asthma- 

no other hereditary diseases

Investigations 

USG

General Examination- 

patient was conscious, coherent and cooperative-

 well built and adequately nourished-

 no pallor- no icterus- no cyanosis - no clubbing of fingers- no lymphadenopathy - no pedal edema -

 bilateral upper limb edema and facial puffiness present - no malnutrition - no dehydration 

Vitals

03/06/23- 

BP: 130/90 mm Hg- Pulse rate: 108 bpm-

 Respiratory rate24 cpm- 

Temperature: afebrile 

- SPO2: 98% at RA-

 GRBS: 783 mg/dL-04/06/23- 

BP: 120/70 mm Hg- 

Pulse rate: 88 bpm- 

Respiratory rate: 22 cpm-

 Temperature: afebrile

 - SPO2: 98% at RA- 

GRBS: 264 mg/dL

05/06/23- 

BP: 110/70 mm Hg- 

Pulse rate: 110 bpm- 

Respiratory rate: 24 cpm- 

Temperature: afebrile -

 SPO2: 100% at RA-

 GRBS: 181 mg/dL

06/06/23- 

BP: 110/80 mm Hg-

 Pulse rate: 114 bpm-

 Respiratory rate: 22 cpm- 

Temperature: afebrile 

- SPO2: 96% at RA- 

GRBS: 143 mg/dLFluid Intake and Urine Output

 

Systemic Examination

Cardiovascular System- no thrills- 

cardiac sounds S1 and S2 heard- 

no cardiac murmurs

Respiratory System- no dyspnea- 

no wheeze- 

trachea position: central- 

breath sounds: vesicular-

 no adventitious sounds

Abdomen- shape: obese- no scars, striae, engorgement