A 50 year old woman with swelling of legs and fever

A 50 year old woman complaints of fever and swelling of legs

22 August 2022

E LOG GENERAL MEDICINE 

Hi, I am Nandini , 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'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. 
 
CHIEF COMPLAINTS:
Patient came with the complaints of fever  since 15 days and swelling of legs since 3 days.

HISTORY OF PRESENT ILLNESS:
Patient got fever and chills before 15 days.Took  paracetamol tablets to relieve it.
She used to be fine morning while doing her labour work.But at night she feels tired due to work and experiences fever.
She visited nearby hospital and get tested for malaria,typhoid,dengue test.All were negative.
But platelets count got reduced.
And doctor of that hospital told that her kidneys are getting damaged.
But she  neglected and didn't took any medication.
She noticed swelling of legs which decreased yesterday night that is Sunday night.
She also noticed some weight loss during fever.

PAST HISTORY:
She have knee joint pains 3 years back.
[She experienced the knee joint pains and leg pains again since fever started]
She had undergone hysterectomy and appendectomy 20 years back.
No history of hypertension
No history of diabetes
No history of tuberculosis, epilepsy, asthma.

PERSONAL HISTORY:
Diet:mixed
Appetite: decreased 
Sleep: adequate 
Bowel: irregular (once in 3 days since 2 years)
Bladder: normal
 But foamy urine is observed and experiences heat.
Addictions:None

FAMILY HISTORY:
Her parents passed away when she is too young.
So she doesn't know any family history.

GENERAL EXAMINATION:
Patient was conscious coherent and cooperative.
Pallor - absent

No clubbing of fingers 

   Pedal edema observed which is of pitting type.
  But reduced from yesterday.

  VITALS:
  PR: 98 bpm
RR: 20 cycles per minute
BP: 110/70 mm Hg
Temperature:98.2 F
PO2: 94%

INVESTIGATIONS:
FEVER CHART

    Ultra sound 


      Hemogram




2D echo

ECG
GRBS-106mg/dl









Popular posts from this blog

A 55 year old woman with loss of consciousness

A 60 year old women resident of sathapuram, admitted in hospital with head spinning since 4 months