general medicine
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Name : Shankara vara prasad
Roll no : 02
2020 Batch
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 comeup with Diagnosis and Treatment plan.
Chief complaints
patient came with complaints of generalized swelling of body since 1 month complaints of shorteness of breath since yesterday morning, generalized body pains since 3 months
history of present illness
Patient was apparently asymptomatic 3 months ago and then she developed edema of both (lower limbs) extending from ankle to knee pitting type, insidious onset , gradually progressive and also developed edema of both upper limbs and facial puffiness since one month . complaints of shorteness of breath not associated with orthopnea ,PND ,chest pain , palpitations.no complaints of decreased urine output
History of past illness
Complaints of generalized body pains with tingling sensation of all four limbs with bloating of abdomen.no complaints of fever cough cold pain abdomen vomiting loose stools burning micturation.known case of hypertension since 3 years on regular medication known case of diabetis since 3 years on regular medication of tablet glimiperide 2 mg not a known case of epilepsy coronary artery disease , thyroid disorders ,tb asthma
Personal history
Married
Occupation - daily labour
Appetite-normal
Non-vegetarian
Bowel -regular
Micturation-normal
No allergies
Habits-no addictions
Family history-
No significant family history
Physical examination-
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadnopathy
No Oedema
No malnutrition
vital signs-
Temperature-98.6
Pulse rate -66/minute
Respiratory rate-14/min
Bp -110/80
SYSTEMATIC EXAMINATION
Cardiac examination
no thrills S1S2 heard
Cardiac murmured are heard
Respiration examination
No Dyspnea
No weeze
Postion of trachea center
Vesicular breath sounds
adventious sounds are not heard
Abdomen
Shape of abdomen-obese
Tenderness-no
Palpable mass-no
Hernial orifices-normal
Freefluid-no
Liver-not Palpable
Spleen-not Palpable
Bowel sounds are heard
Cns
Conscious
Speech -normal
Cranial nerves-normal
Sensory system-normal
Motor system-normal
Reflexes-normal
Cerebral signs-normal
Finger nose in coordination-yes
Knee heel in coordination-yes
Mentural history'
Age of menarche 13 years
Since 3 menopause
Obestric history
Age of marriage 15years
Age at first child birth 18years
Para 2
Number of living children 1
Birth history
2 deliveries Cesarion
Investigation