Hi, I am S.Sai Srija , 5th semester 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 patients 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 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.
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 throughout the piece of work whatsoever.
A 70 year old woman,a house wife R/O Chityala came to the OPD on 11th September 2023 with the chief complaints of blurring of vision since 1 year
Odema of right leg and right foot since 10 days
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 10 days back then she developed odema of right leg and foot, pitting type which is sudden in onset and progressive.It was associated with pain since 10 days,burning type,aggrevated on touch,exertion.
H/O cough,general weakness,headache, vomiting ,shortness of breath while walking.
No H/0 burning micturition,hematuria.
PAST HISTORY :
Not a known case of HTN/ DM/ Asthma
No H/O similar complaints in the past
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
Diet - Mixed
Appetite- Normal
Sleep -Adequate
Bowel and bladder movements - regular
PHYSICAL EXAMINATION :
GENERAL EXAMINATION:
The patient is conscious,coherent,
Cooperative.
Well oriented to time,place and person.
Pallor -present
Icterus-No
Clubbing - No
Cyanosis - No
Lymphadenopathy-No
Pedal odema- Present
Vitals:
BP :110/70 mmHg
PR :102bpm
RR:16cpm
SpO2:99%
LOCAL EXAMINATION:
No skin changes
Pitting,tender
SYSTEMIC EXAMINATION:
CVS :
S1,S2 heard
No murmurs
Respiratory system:
No wheeze
Central position of trachea
Normal vesicular breath sounds
Abdomen :
No palpable masses
No scars
Umilicus central
No organomegaly
CNS:
No focal neurological deficits
INVESTIGATIONS:
CBP
