GENERAL MEDICINE CASE DISCUSSION

 22 December 2022

General medicine case discussion

E LOG MEDICINE CASE

22/12/2022

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: Kondakindi Vrithika Reddy

Roll no : 59

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.

A 45year old female house wife by occupation came to general medicine  OPD with chief complains of: swollen left leg with slight pain. 

History of present illness: 

Patient has complained of swollen left leg since 10-15 years that reduces after 15 days and reoccurs after a few days. Dragging type of pain is seen when the leg is swollen. 

Personal History:

Appetite: normal

Diet: Mixed

Bladder habits: regular

Bowel moments: regular

Addictions: Nil

Known Allergies: nil 

Past History: 

There is no history of DM,HTN,TB, EPILEPSY.

No history of blood transfusions.

History of previous surgeries: hysterectomy

Family History:

No relevant family history. 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: absent

Vitals:

Temperature: 98.1 degrees Fahrenheit 

Pulse rate: 74 beats per min

Respiratory rate: 

BP: 100/70

SPO2: 100%

GRBS: 99mg% 

Systemic Examination:

A. CVS

1. S1 and S2 sounds heard
2. No audible mummers
3. No trills

B. Respiratory system:

1. Dyspnea: absent
2. Position of trachea: center
3. Normal vesicular breath sounds are heard
4. No adventitious sounds

C. Per-abdomen:

1. Scaphoid shaped abdomen
2. No visible swellings 
3. No visible scars and injuries
4. No tenderness
5. No palpable mass 
6. Bowel sounds: not heard

D. CNS:

1. Conscious 
2. Speech- normal
3. Signs of meningeal irritation - Nil
4. No neck stiffness
5. No kerming's sign
6. Cranial system - intact 
7. Motor system - intact 
8. Sensory system - intact 
9. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

ECG:

Provisional Diagnosis: Left leg edema 

Treatment: