72years old female with dov of right and left eye ,knee pain and hypertension
Hi, I am Y.Varunkarthik , 5th semester medical student.
This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
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 come up with a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Chief Complaint
Patient gave the chief complaint of Complete loss of vision in right eye since 1 year ; diminution of vision in left eye since 6months;
Bilateral knee pain since 1 year
History of presenting illness
Patient was apparently asymptomatic 1year ago,then she developed
*Knee pain:
Since 1year ,which is insidious in onset , intermittent, dragging type of pain, extending upto foot, aggravated by walking, no relieving factors
* Pedal edema:
Bilateral
Pitting type
Extending upto knee
* History of fever 10 days back at the same time diagnosed with hypertension
* History of trauma to left leg one year ago
* No history of headache , general weakness , giddiness
* No history of chestpain, cough, cold ,sob
*No history of burning micturition, nausea, vomiting
Past history
K/c/o hypertension
N/k/c/o DM, epilepsy, asthma, tb, thyroid
Past surgical history
Mastectomy of left breast 20 years back
Personal history
Married
Pure vegetable diet
Normal appetite
Bowel & bladder movements are regular
Adequate sleep
Had a habit of consuming toddy occasionally
Had an addiction of taking bedi in past , now stopped for more than 10years
Family history
Not significant
General examination
Patient is conscious, coherent, cooperative
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema - bilateral
Pitting type extending upto knee
Vitals
Temperature
Bp: 130/ 70 mmhg
Pulse : 95bpm
Grbs:82
Systemic examination
A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs
B. RESPIRATORY SYSTEM
- no dyspnoea
- No wheezing
- central trachea
- vehicular breath sounds
C. ABDOMEN
- scaphoid shaped abdomen
- No tenderness
- No palpable mass
- non palpable liver and spleen
C. CNS
- conscious and coherent
- normal speech
Investigation