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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
45 year old female by came to opd on 30-6-2022 with chief complaints of :-
*Swelling of both legs upto knee right more than left since 20 days and
* Pain in the abdomen since 10 days
HISTORY OF PRESENTING ILLNESS:-
Patient apparently asymptomatic 20 days back then she developed swelling of both legs upto knee (right more than left ) which is sudden in onset and gradually progressive and associated with pain while walking and grade 3 dyspnea ( dyspnea on walking upto washroom) .
She is having pain in right hypochondriac and epigastric region since ten days associated with pain in shoulder area radiating to neck
Personal history:-
She is a daily wage labourer works predominantly in paddy and cotton fields but during summer there was no work so she worked in a college hostel by staying in it. There she washed dishes after washing she used to watch tv until there is another work .The day before the onset of lower limb edema she was at home for some function ,she ate food and went to bed but after she woke up she found herself with swelling,not only of legs but also her face.Then she went to local doctor, they gave her medication for a week , swelling subsided but it reappeared as soon as she stopped the medication ,after one week she came to our opd on 30-6-2022.
PAST HISTORY:- no similar complaints in the past,
Not a know case of DM,HTN ,asthma,TB, epilepsy
PERSONAL HISTORY:-
Diet :- mixed
Appetite :-reduced
Sleep:- adequate
B&B :-regular
Addictions:-none
GENERAL EXAMINATION:-
Patient is conscious, coherent cooperative well oriented to time place person
Moderately built, moderately nourished
Vitals:- bp-120/80
Pulse rate-75
Temp -afebrile
Respiratory rate-16cycles/ min
Paller:- present
Icterus:- absent
Cyanosis :- absent
Clubbing :- absent
Koilonachia:- absent
Generalized lymphadenopathy:- absent
Edema :- edema of both lower limbs upto knees
SYSTEMIC EXAMINATION:-
Cardiovascular System :
Inspection :
Precordium:-
No precordial bulges.
No engorged veins.
No scar/sinus.
Apex Beat : appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.
Chest wall Defects : None.
PALPATION :
Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 5th Intercostal Space.
AUSCULTATION :
S1 ,S2 heard.
Respiratory system:-
Normal vesicular breath sounds are heard
Abdominal examination:-
Inspection:- Scaphoid, no scars
Palaption :- tenderness in epigastric and right hypochondriac regions
Auscultation :- narmal bowel sounds are heard
Cns examination:- no focal neurological deficits
Investigations:-
Provisional diagnosis:- heart failure??
Treatment giving:-
Lasix 20 mg
Shelceal 500 mg
Chymoerol fort
On 4-7-2022,after two days of treatment
On 5th July
On 6th July
On 7 th July
Treatment giving from 6 -7-2022
*Lasix
*Shelcal
*Chymoral forte
*" DCE 200 mg"
References(investigations) taken from cherukupallipavan.blogspot.com
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