A 50 year old woman complaints of fever and swelling of legs
A 50 year old woman complaints of fever and swelling of legs
Hemogram
22 August 2022
E LOG GENERAL MEDICINE
Hi, I am Naalla Gayathri , 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
ECG
