A 47 year old female presented with shortness of breath, pedal edema, distended abdomen and lymphadenopathy

Hi, I am Souraja Acharya, 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.

Chief complaint
A 47 year old woman who is a housewife presented to the OPD with shortness of breath, abdominal pain and distension, pedal edema and itching in the whole body. The patient complained of Shortness of breath since 10 days, itching since 1 month, Backpain since 7 days and abdominal pain since 7 days. Patient also complains of itching in the whole body and swollen feet and abdomen. 

History of present illness

Patient was asymptomatic 4 months back. 4 months back, patient developed abdominal distention and pain which subsided on receiving diuretics. A month later, she developed edema in the legs as well for which she presented to the OPD. 
(Enter daily routine) 

History of past illness

Patient has been suffering from type 2 diabetes mellitus since 6 years for which she has been receiving anti diabetic drugs. She also has hypertension and hypothyrpidism since 5 months. Patient underwent tubectomy 20 years ago. 
No CAD
No Asthma
No epilepsy
No syphilis

Family history

Mother had diabetes
No other significant family history

Allergies

No allergies

drug history
(Enter drug history)

Personal history
(Ask personal history) 

General examination

Conscious, coherent and cooperative
Well built
Hydrated
Pallor absent
Icterus absent
Cyanosis absent
No clubbing of fingers
Pedal edema present
Abdominal edema present
Cervical lymphadenopathy present

(Check vitals of patient)

Systemic examination
(Check cvs of patient)
(Check resp of patient)
(Check abdomen)





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