A 66 year old woman resident of narketpally came with chief complaints of cough
28 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:26 April 2023
CHIEF COMPLAINTS:
Patient complaints of cough and a general health checkup.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 15 days back. She then developed edema in both lower limbs which was pitting type and extended upto below the knee. No history of oliguria. And after somedays she had fever for 1 to 2 days and then after she developed cough. She went to nearby doctor and edema relieved by medication. But cough is not totally subsided. Cough was productive with sputum and sometimes she had dry cough. It aggrevated on lying down. As that doctor suggested for complete blood picture, they came to know her hemoglobin was very low. So they admitted here after this.
PAST HISTORY:
She is a known case of hypertension since 20 years. She had undergone a surgery for her left eye.
She was diagnosed with cervical cancer 10 years back. It was associated with white discharge and lower back pain. She then undergone radiation therapy for 21 days in continental hospital.
No history of diabetes, asthma, thyroid, TB, epilepsy, coronary artery disease.
OBSTETRIC HISTORY:
She had 6 children .
First 2 girls and then 4 boys.
Normal delivery.
Tubectomy was not done.
PRESENT HISTORY:
Diet:mixed
Appetite: normal
Weight loss due to radiation therapy.
Sleep: adequate
Bowel: regular
Bladder: regular
Addictions:None (Used to consume toddy occasionally very long back )
FAMILY HISTORY:
No significant family history.
ALLERGIC HISTORY:
No known allergies.
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Well oriented to time,place and person.
Thin buit and moderately nourished.
Pallor - present
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No edema
