A 65 year old patient came to general medicine OPD with the chief complaints of swelling allover the body
GENERAL MEDICINE E-BLOG
Hi, I am M. Sohith Mahadeva Reddy of 5th semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of his/her condition.
HISTORY OF PRESENTING ILLNESS
She was apparently assymptomatic 1 week ago.
Then she developed sudden onset of generalized edema which was moderate in the beginning and gradually increased in the evening.
It was associated with dypsnoea on exertion.
It is not associated with pain, rise in temperature, nausea, vomiting and diarrhoea.
She was taken to Suryapet hospital where she received medication which showed slight improvement and she came here for complete recovery.
HISTORY OF PAST ILLNESS
She had history of non radiating lower back pain 5-6 years ago for which she was admitted to the hospital and recovered.
She was found to have partial hearing loss since childhood.
No h/o HTN, DM, Asthma, CAD, TB, Epilepsy
FAMILY HISTORY
She has no significant family history
PERSONAL HISTORY
Married
Mixed diet
Normal appetite
Adequate sleep
Bowel and bladder movements regular
No burning micturition
No Allergies
No Addictions
GENERAL EXAMINATION
The patient was conscious
Well oriented with time, place and person
Cooperative and coherent
No Pallor
Icterus present along with slight yellow discolouration of palms and nailbeds.
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No dehydration
Pitting type pedal edema - Grade 4 below knees
VITALS
PR: 76bpm
Temp: afebrile
BP: 110/70 mm of Hg
RR: 19 cycles per minute
LABORATORY INVESTIGATIONS
