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I have 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 diagnosis and treatment plan.
A 47 yr old female,resident of Narketpalli,homemaker by occupation presented to OPD with cheif complaints of
Pedal edema since 15 days
SOB since 15 days
Productive cough since 13 days
HISTORY OF PRESENTING ILLNESS:
Pt was apparently asymptomatic 15 days back then she developed bilateral pedal edema (pitting type) below level of knee,which was persistent.
Then she developed shortness of breath(grade 2) 15 days back which aggravated in 2 days to grade 3 where she was unable to perform her regular activities like taking bath and household works .so she went to hospital and her hb levels were found to be 3.6, she was advised to get a blood transfusion and thus was sent to our hospital.This complaint reduced since last 4 days
Since 13 days she had productive cough which was yellowish white in colour and non blood stained ,non foul smelling
The cough initially was so severe that used to wake her up from her sleep due to repeated cough and resulting breathlessness due to that.
H/o fever since 3days associated with chills and rigor
no history of weigh loss
no history of malaise
she noticed left side facial puffiness on 31st December after 2 hr it reduced spontaneously
no abdominal distention
Palpitations
Paresthesia in hand
Loss of taste
Past History
from last 1 nd half year there is pedal edema which is on and off
no history of HTN,diabetes, asthama,TB,thyroid and Epilepsy
Menstrual History
she attained menarchy at the age of 12yrs
earlier she used to have regular 30 days Menstrual cycle with 3 days flow ,no clots
from 22march,2022 she is having regular 20 days cycle ,heavy Menstrual bleeding for 5 days for which she went to hospital and was diagnosed with fibroids in uterus and was advised for hysterotomy but due to her low hb level surgery and financial issues it was not done.she under went blood transfusion later her Hb was found to be 8gm% which was not adequate for surgery
Since last 6 months spotting is seen for every 15 to 20 days of cycle
Personal history
Normal appatite
Mixed diet
Adequate sleep
Regular Bowel and Bladder movement
No addictions
No allergies
Daily routine-she wake up at 5 am does daily work(sweeping,washing cloths)then she will have a glass of milk at 12 pm she will have rice ,dal and curry then she will have sleep for a hour
Watch TV for 1 to 2 hr then at 9pm she will have dinner(chapati and curry)
Sleep at 10 pm
diet history
1 glass milk-129 cal,8g
Lunch-rice 2 cups-414 cal,6.6g
Curry 1 cup -80cal,6g
Dal 1 cup -89cal,7g
Milk 1 glass -129 cal,6.6 g
Dinner-chapatti2 and half-172 cal,8g
Curry-80 cal,6
Total -59.6 g and 1091 cal
She is deficit of 1509 cal
Family history
No significant family history
Treatment history
Medroxy progesterone acetate-once daily for 2 month
Dexorange from last 4 days
General examination
Patient was consious, coherrent and co-operative. Well oriented to time place and person. Well built and nourished
Pallor present
B/L pedal edema(pitting type) present
No icterus
No clubbing
No cynosis
No generalized lymphadenopathy
Blackish discolouration of tongue and teeth is notes since last 5 days due to use of syrup dexorange
Vitals
Pulse-114
BP 120/70
Respiratory rate-19cpm
Spo2-96%
Temp-afebrile
Jvp raised
Systamic examination
Cvs-
Parastatal heaves are noted
JVP- raised
S1,s2 heard no murmurs
Rs- Trachea central
Normal vesicular breath sounds heard
Crepts are heard on the right infrascapular
Per abdomen-
INSPECTION: abdomen :round
Moves with respiration
No abdominal distension
Umblicus is central and inverted
No engorged veins
C section scar can be seen below umbilicus scars
no sinsus are seen
Hernias orifices are clear.
PALPATION:
All inspectory findings are confirmed
No tenderness in the abdomen
No palpable liver or spleen
PERCUSSION:No significant fingings
AUSCULTATION: Bowel sounds heard
No bruits.
Cns-no focal neurological deficit
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
dimorphic anemia
right heart failure
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