GENERAL MEDICINE E-LOG

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32 CH SRILEKHA, 5th sem

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio

CASE

A 45 year old female resident of Thalakkampadu , daily laborer by occupation came to camp with chief complaints of 

1. Bilateral pitting type of pedal edema since 30days

2. Shortness of breath since 10days

3. Neck pain since 10days

4. Abdominal pain since 10 days

Then she came to hospital for further examination .

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 20 days back and then developed gradual bilateral pitting type of edema since 20 days.

 When she first noticed swelling on her legs . She visited local RMP, then he prescribed some medication and it got relieved for few days . But again legs started swelling then she went to camp and came to our hospital . 

HISTORY OF PAST ILLNESS

No history of diabetes 

No history of HTN

Not a known case of thyroid 

PERSONAL HISTORY

Marital status : Married 

Occupation : Daily laborer

Diet : Mixed 

Loss of appetite

Sleep : adequate

Bowel movements : Normal

Micturition : Normal

Addictions : Toddy drinker occasionally 

But stopped drinking since 1 year

She has no known Allergies. 

TREATMENT HISTORY

She took some medicines prescribed by Local RMP for pedal edema

FAMILY HISTORY

No Significant family history

DRUG HISTORY

Not Significant

GENERAL EXAMINATION

Patient is conscious , coherent , cooperative and examined in a well lit room. 

VITALS

Pulse Rate: 78/min

Blood pressure: 140/80mmHg

Respiratory rate: 18/ min

Temperature : Afebrile

Spo2 : 98%

PHYSICAL EXAMINATION 

Moderately built and nourished

Pallor : absent 

Icterus : absent

Cyanosis : absent

Clubbing of fingers and toes : absent 

Lymphadenopathy : absent

Edema : B/L pitting pedal edema is present 


Malnutrition : absent 

Dehydration : absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 are heard 

No thrills

No murmurs

RESPIRATORY SYSTEM

Dyspnea : present

No wheezing

Trachea : central

BAE +

PER ABDOMEN

Shape : Scaphoid

Tenderness : present

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

CNS 

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves :  intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal

INVESTIGATIONS

Colour Doppler 2D Echo


ECG


Complete blood picture (CBP)


Complete Urine Examination (CUE)


Blood grouping and Rh type


Renal function test (RFT)


Liver function test (LFT)


Random blood sugar


Ultrasound (USG)


PROVISIONAL DIAGNOSIS

Pedal oedema

TREATMENT

T.LASIX 20mg PO/BD

T.SHELCAL 500mg PO/OD

T.CHYMEROL FORTE TID

T.PAN 40mg OD 




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