This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 plan.
50 year old female patient farmer by occupation resident of miriyalaguda came to the hospital with the Chief complaints of
Generalized weakness
Loss of appetite
SOB (grade 2 or 3)
Body pains
Loss of appetite
All since 6 months
Hopi
Patient was apparently asymptomatic 2 years back
Then she developed swelling in the left lower leg which later extended to the whole body
She was admitted in osmania and treated with medications accordingly
1year back she developed SOB Grade 2 generalized weakness easy fatiguability with Loss of appetite and weight loss
Not associated with palpitations cough or cold
She had fever which low grade intermittent not associated with chills and rigors relieved on medications
She also had hematuria
She had gone to a local hospital where she was diagnosed with anemia and 5 units blood transfusion was given in a span of 20 days
6 months back she had similar complaints and had gone to hospital where they found anemia again
6months back on the right neck 3 to 4 blisters
She had Itching
Taken medication to relieve
Itching persisted
1week back she was transfused with 2 units of blood
Then she developed a high grade fever with chills and rigor
Taken medications and relieved
She came here as she was unsatisfied with the given treatment.
History of past illness
No history of DM/HTN/Epilepsy/asthma/TB
Known case of hepatitis since 1yr
Confirmed by ONCC hyderabad
Treatment history
7 units of blood since 1 year
Family history
No significant history
Personal history
Married
House wife
Loss of appetite
Mixed diet
Regular Bowel movement
History of hematuria since 1yr which is intermittent
No known allergies or addictions
Menstrual history
Attained menopause 10yrs back
General examination
No cyanosis, clubbing of fingers, lymphadenopathy, pedal edema
Malnutrition present
Systemic examination
CVS
No thrills and murmurs
S1 and s2 felt
Resp
No dyspnoea and wheeze
Centrally placed trachea
Vesicular breath sounds heard
No adventitious sounds
Abdomen
Scaphoid abdomen
Mild tenderness and palpable mass in the left hypochondrium and left flank region
No free fluid
Liver not palpable
Spleen palpable
Bowel sounds yes
CNS
Conscious and coherent
Normal speech
No neck stiffness
No kerning sign
Investigations
