Medicine blog: A 55 yr old female with Sob and pedal edema

Gen med case presentation;

Jan 20,2022

Name;Ramya reddy pebbeti.

Roll no;105 .

This is 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 centred 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 diagnosis and treatment plan

Following is the view of my case :

CASE PRESENTATION ;

DOA:19/01/22

chief compliants:

A 55 yr old female who is a farmer by occupation came to the opd with a chief compliants of

* Sob since 15 days

* Pedal edema since 15 days

Illness events In her life are;

8 yrs back she is diagnosed to have hypertension and she is on regular medication

5 years back she had an upper limb fracture for which she went to hospital and got treated for that and her creatinine levels were high ( from hospital reports) serum creatinine-2.8mg/dl

6 months back she tested positive for covid

5 months back her Cr level are 4.5 mg/dl

Current Cr levels are 7.9 mg/dl( on 17/01/22)

Now she came to our opd complaining of

*Sob since 15 days ( grade - 3)

*Pedal edema - since 15 days ,non pitting type

*Decreased urine output

Past history;

K/c/o HTN since 8 years

H/o taking NSAIDS for 1 year for OA ( given By a local doctor)

Personal history:

Diet- mixed