45 year old married women, labour from Nalgonda came to hospital, and also had generalized swelling since 3 months.
24 April, 2023
E LOG GENERAL MEDICINE
Hi, I am Nandini, 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.
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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:
Fits, fever, head heaviness, vomiting since 1 day and was admitted in casualty on 23rd April 2023
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months ago. One day ahe noticed swelling in left leg then she went to work later when she returned home she observed the edema progressed to entire body(limbs, face, abdomen).
Edema was sudden in onset and rapidly progressing and associated with pain.
Pain started with edema it was dragging type, duration was throughout the day, aggravated by movement and lying in supine position, pain was relieved by medication and sitting position. Pain eventually spread throughout body along with edema.
2 months ago when the swelling increased she went to sindhura hospital where she was diagnosed with kidney problem then she was given medication which she used irregularly so edema didn't decrease then she came to KIMS hospital.
In KIMS hospital she was told to undergo dialysis for which she was frightened and refused.
Then she went to Nalgonda hospital there she suddenly developed sob.
She immediately came to KIMS hospital.
Negative history:no fever, rise in temperature, cough, cold, burning Micturition, oliguria,nausea vomiting , headache, loose stools, constipation, nsaid absue.
PAST HISTORY:
No similar complainys in past.
No history of tuberculosis, epilepsy,asthma,CAD.
2-LSCS(lower segment Ceasarian Section).
4 years ago diabetes she fainted while working when Rmp checked and diagnosed with diabetes took regular medication.
3 years ago diagnosed with hypertension she had fever, went and was diagnosed.
2 years ago she had thorn prick thorn was removed cast was kept due to which her left distal Interphalangeal joint was flexed and can't extend the joint.
Obstetrics- 1st boy 24years
2nd boys 18 years
Both were lscs.
FAMILY HISTORY:
Mother had hypertension, diabetes, Bilateral kidney issue.
No other history.
PERSONAL HISTORY:
Diet: mixed (but non veg was stopped after doctor visit).
Appetite: normal
Bowels : regular
Bladder: regular
Sleep : inadequate due to tension, stress due to surgery.
Addictions:None
ALLERGIC HISTORY:
No known allergies.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Pallor is present.
Icterus is absent.
Clubbing fingers absent.
Cyanosis absent.
Lymphadenopathy absent.
Edema absent.
VITALS:
Temperature: Afebrile
PR: 108 bpm
RR: 26
BP: 150/110mm hg
