gm blog- 20/4/2023 45 yr old female patient

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 comments on 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 prognosis.

A 45 year old female patient residence of kattangur came to opd with 
Cheif complaints of generalised body pains since 3 months and generalised swelling of body since 1 month and shortness of breath of grade 2 since yesterday morning sudden in onset aggravated during walking and relieved by taking rest.
History of presenting illness:
Patient was apparently asymptomatic 3 months back and then developed generalised body pains since 3 months which is pricking type and aggravated while doing daily routine work and walking and not relieved on medication  
C/o of generalised swelling all over the body 1 month back which is gradually progressive and swelling in legs is aggravated during walking and during nights and not relieved on medication
C/o Shortness of breath from yesterday Morning which is sudden in onset which is of grade 2
No H/o palpitations and chest pain 
No H/o burning micturition, decreased urine output.
No H/o fever and headache.
Past history: 
She is a known case of diabetes since 3 years and 
known case of hypertension since 1 year and is on medication.
Not a known case of tuberculosis,asthma, lymphedenopathy, epilepsy and thyroid disorders.
Personal history:
Mixed diet, 
adequate sleep,
Regular bowel and bladder movements 
Decreased appetite
No drug allergies are present
Occasionally toddy consumption.
Family history: Not significant
General examination:
Patient is conscious coherent and well oriented to place and time.
Moderately built and moderately nourished.
VITALS
Temperature: Afebrile on touch
Blood pressure: 150/100 mmHg
Pulse rate: 72bpm
Respiratory rate: 26 cpm
Pallor-present
Pedal edema present pitting type
iceterus:absent 
Cyanosis: absent
Clubbing:absent
Lymphedenopathy:absent 
Systemic examination.   
CVS EXAMINATION: 
INSPECTION.
Shape of chest wall- eliptical
No precordial bulge present 
No kyphoscoliosis present
Apical impulse- present 
No dialated veins and scars are present
Jugular venous pulse- normal
PALPATION.
Apical impulse- present in the 5th intercostal space
Pulsations are heard(aortic, pulmonary and mitral areas)
No thrills and murmers present 
PERCUSSION
All the borders of heart are felt
AUSCULTATION.
S1 S2 are heard (tricuspid,aortic and pulmonary areas)  
PER ABDOMEN:
INSPECTION:
Shape of abdomen: distended
Visible scars 
Umblicus is inverted
No engorged veins present
No visible pulsations
Abdominal wall movements are normal.
PALPATION:
Superficial- 
Temperature-afebrile 
Tenderness-absent
Liver - not palpable
Spleen - not palpable
PERCUSSION:
Liver span-
Dull note is heard because of fat 
ASCULTATION: bowel sounds are heard
PROVISIONAL DIAGNOSIS: Anasarca and anemia.


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