45 year old female presented with swelling of right leg.
E LOG GENERAL MEDICINE.
Hi, I am Anvitha, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.
CASE SHEET.
Chief complaints and duration.
A 45 year old female patient who was a cotton picker by occupation presented with swelling of right leg. She complained of pain in the swelling and it was pitting type. Swelling started since 20 days.
History of present illness.
Patient was apparently Asymptomatic when she developed swelling and pain. She first visited a local RMP for which she was relieved with medication (medication not known). The swelling did not get reduced so she came to the hospital. When the temperature of the legs was checked the right swelled leg had heightened temperature. She had chest pain (right hypochondriac region) and neck pain. She is able to walk for a small distance but experiencing weakness when tried to walk for a long distance.
History of past illness.
K/C/O hypertension since ten days. No history of pedal oedema. N/K/C/O DM, thyroid disorder, CAD, Asthma, TB.
Personal history.
Patient is a daily wage worker (cotton picker) by occupation.
Bowel movement is regular.
Micturition is normal.
No history of Allergy.
No addictions.
Family history.
No relevant family history.
PHYSICAL EXAMINATION.
A. General Examination
Pallor is present.
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet
No dehydration
Temperature: 98.6 F
Pulse: 88/ min
Respiration: 16/min
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
No dyspnea
No wheezing
Vesicular breath sounds .
D. Abdomen
Shape of abdomen - Obese
No tenderness
No Palpable mass
E. Central nervous system
Patient was conscious, coherent and cooperative.
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