Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.
Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
CASE:-
A 60 year old female, who was an agricultural labourer by occupation (but has stopped working since 4 years), came to the hospital with complaints of pain in both knees since 4-5 years, facial swelling since 2-3 months, pedal edema since 1 week.
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic 4-5 years ago. She then started developing pain in both her knees which is aggravated on walking and standing, relieved on resting and medications (painkillers). She stopped working due to the pains.
2-3 months ago, she developed facial puffiness which was insidious in onset and gradually progressive in nature. It appears maximally in the mornings and gets relieved by the end of the day.
1 month ago, she had a tooth extraction on the left side and still has facial puffiness on the left side.
1 week ago, she had pedal edema upto her ankles which was pitting in nature. This also appears maximally in the morning and subsides by the end of the day. Her edema greatly subsided by itself after a week.
She came to the hospital now to find a working solution for her joint pains and to find out about why her pedal edema appeared and disappeared.
DAILY ROUTINE:-
The patient wakes up in the morning at 5:30 and begins household chores, eats breakfast at 8:00. She smokes tobacco at this time.
She then passes her time by talking with family members or guests till 11:00, when she cooks her lunch and eats lunch late, around 3:00-4:00pm
She has tea occasionally in between, when she visits family. She spends time sleeping or talking with friends and family in person or on the phone.
At night, she doesn't feel hungry. She may or may not smoke tobacco again. She then sleeps at around 10:00pm.
PAST HISTORY:-
Not a known case of diabetes, hypertension, CVA, CAD, TB, asthma
FAMILY HISTORY:-
Not significant.
TREATMENT HISTORY:-
The patient has a history of using NSAIDS 3-4 days a week since 4 years for the joint pains, suggested by and RMP.
PERSONAL HISTORY:-
Appetite: normal
Diet: mixed
Sleep: adequate
Bowel movements: regular
Micturition: normal
No known allergies
Addictions: Smokes tobacco once or twice a day everyday
MENSTRUAL HISTORY:-
Attained menopause 20 years ago
OBSTETRIC HISTORY:-
Age at marriage: 18 yrs
Age at first childbirth: 20
Obstetric formula: G5P5L5
All normal vaginal deliveries
GENERAL EXAMINATION:-
The patient is conscious, coherent, cooperative and well-oriented to time, place and person.
The patient is moderately built and well-nourished.
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy
Pedal edema present in right foot (grade 1)
Vitals:-
Temperature: Afebrile
Blood pressure: 120/80mm Hg
Pulse rate: 82 bpm
Respiratory rate: 18cpm
SYSTEMIC EXAMINATION:-
CNS: Patient is conscious, coherent and cooperative, well-oriented to time, place and person
CVS: S1, S2 sounds heard, no murmurs
Respiratory system: trachea central, normal vesicular breath sounds heard, no added sounds
Abdomen: distended, no palpable organs.
INVESTIGATIONS:-
19.07.2023:-
Ultrasound:-
ECG
PROVISIONAL DIAGNOSIS:-
Facial puffiness under evaluation
TREATMENT:-
Took Potassium citrate and magnesium citrate for pedal edema, given at government hospital.
Aspirin
Rosuvastatin
Furosemide
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