General Medicine Case Discussion

General Medicine Case Discussion

June 03, 2023
General medicine case discussion

E LOG MEDICINE CASE

03/06/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.


Name : U.Sri Vidya 

Roll no : 121

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission: 01- 06-2023
A 55 year old female patient came to medical OPD with
Chief Compliants -
-Difficulty in breathing since 5 years.
-  lower back ache since 1 year.

History of presenting illness -
Patient was apparently asymptomatic 5 years back then she started developing shortness of breath which was insidious in onset and gradually progressive .
Intially Grade - 1 aggravated since one year and gradually progressed to Grade 3 .
SOB aggravates on walking and relieved with medication .
She also has lower back ache since 1 year, radiating down to both the lower limbs, it aggravates on bending forward , relieved with medication .
It is associated with tingling and numbness , occasionally associated with muscle spasms .
History of pedal edema since 1 year which is of pitting type .
History of increased appetite,nocturia(5-6 times).
No history of chest pain, palpitations.
No complaints of fever, loose stools, vomitings, burning micturition , decreased urine output.

Past history -
No known history of DM , HTN , EPILEPSY, THYROID,CAD.
No surgical history.

Personal history -
Appetite - Normal 
Sleep - Adequate 
Diet - Mixed 
Bowel and bladder movements - Regular 
Allergies - None
Addictions - None

Family history -
No significant family history.

General Examination -
Conscious
Coherent
Coordinated
Well oriented to time, place and person
Moderately built
Moderately nourished
Pallor - Present 
Icterus - Absent 
Cyanosis - Absent 
Clubbing of fingers - Absent 
Lymphadenopathy - Absent 
Pedal edema - Present



Vitals -
Temperature - Afebrile
Blood pressure -100/70 bpm 
Respiratory rate - 16 cpm
Pulse- 77 bpm


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