A 45 year old woman labour by occupation resident of nalgonda came with cheif complaints of difficulty in breathing and generalised swelling

April 26, 2023

26 April 2023

E LOG GENERAL MEDICINE

Hi, I am Naalla Gayathri , 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'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.

DATE OF ADMISSION:23 April 2023

CHIEF COMPLAINTS:

Patient complaints of difficulty in breathing on date of admission i.e. 23rd April and swelling of limbs and face since 3 months.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 months ago. Then she noticed edema of left leg,then she went for work. When she came back to home she noticed edema of all limbs,face,abdomen.

Edema was sudden in onset and rapidly progressed

and associated with pain.

Dragging type of pain and she experienced it throughout the day.

Pain relieved by medication and sitting but aggrevated by movement and lying on supine position.

Nearly 2 months back she went to sindhura hospital where she was diagnosed with kidney disease. She took medication for 1 month irregularly and edema didn't decrease. So she came here. Here, she was told to undergo dialysis. She got tensed and refused and went to nalgonda hospital. There she suddenly developed shortness of breath and she immediately came back here.

It is not associated with fever, rise in temperature at that region, cough, oliguria, burning micturition, nausea, constipation or loose stools.

PAST HISTORY:

No similar complaints in past.

2 LSCS (24 years and 18 years ago respectively)

Tubectomy done.

Known case of diabetes since 4 years ( diagnosed as she fainted while working)

Known case of hypertension since 3 years.

2 years ago she had thorn prick ( thorn was removed ,cast was kept. Now her left distal interpharyngeal joint is flexed and can't extend)