This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 patients clinical problems with collective current best evidence based inputs. Hope this will be informative!
* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
Chief complaint
A 45 year old female resident of Thalakampadu, who is a labourer by occupation came to the camp with chief complaints of -
Bilateral pedal edema since 20 days
Neck pain, shortness of breath
Abdominal pain since 20 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 20 days back ,Then she gradually developed bilateral pedal Pitting type of edema on lower limbs since 20 days.
Initially edema was present on both the limbs but the edema of left limb got gradually reduced but not completely relieved.
PAST HISTORY:
No history of hypertension
No history of diabetes
Not a known case of thyroid
PERSONAL HISTORY:
Mariatal status - married
Appetite-normal
Diet - mixed diet
Bowel - regular
Micturition - normal
No known allergies
Alcohol - occasional toddy drinker
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
VITALS :
Temperature-
Pulse rate -78 beats / min
Respiratory rate-18/ min
BP - 140/80 mm
SP02 at room Air 98%
PHYSICAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No
SYSTEMIC EXAMINATION:
*CVS -
S1 and S2 heard
No thrills
No murmurs
RESPIRATORY SYSTEM -
Dyspnoea present
No wheezing
Trachea - central
Bronchial artery embolisation
ABDOMEN -
Shape- scaphoid
Tenderness- present
No palpable mass
Hernial offices normal
No free fluid
No bruits
Liver & spleen arw not palpable
CNS -
Consious
Speech normal
No signs of meningeal irritation
Cranial nerves intact
Motor system - normal
Sensory system - normal
Reflexes normal
INVESTIGATIONS
Color 2D echo
Electrocardiogram(ECG)
Complete Blood picture(CBP)
Complete Urine Eamination (CUE)
Blood grouping & Rh type
Renal Function Test (RFT)
Liver Function Test(LFT)
PROVISIONAL DIAGNOSIS :
Bilateral pedal edema
TREATMENT
T.LASIX 20mg PO/BD
T.SHELCAL 500mg PO/OD
T.CHYMEROL FORTE TID
T.PAN 40mg OD
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