general medicine blog 1

 Hi, iam maheshwari  of 3rd semester. This an online E logbook to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.
Cheif complaints:
A 47 year old female which cheif complaints of pedal edema shortness of breath & abdominal distension and cervical lymphadnopathy 
HISTORY OF PRESENT ILLNESS:
patient was apparently asymptomatic 6 years back and had generalized body weakness for which she went to hospital and diagnosed it as diabetes mellitus 2 and was on regular medication .
2 months back patient had pedal edema below hip ,pitting type and abdominal distension for which she visited near by hospital and was diagnosed hypotension and hypothyroidism after necessary test pedal edema was subsided on medication but abdominal distension was not subsided for which she came to her hospital and was admitted and treated for 1 weak for low SAAG ,low protein ascites secondary to? Kochi?diabetic nephropathy .
lymph node was enlarged in cervical region for which FNAC was done now patient came for excisional biopsy. 
PERSONAL HISTORY:
Marital status -married 
Occupation-housewife 
Appetite -decreased 
Bowel -regular 
Micturation-normal 
Allergies -no 
Addiction -nill 
FAMILY HISTORY :
Not significant 
PHYSICAL EXAMINATION :
No pallor
No icterus 
No cyanosis 
No clubbing of finger 
Lymphadnopathy "palable lymphnodes"are present at posterior triangle of neck 
Oedema of foot "yes" (pitting type)
No malnutrition 
No dehydration 
VITAL SIGNS :
Temperature -98.6F
Pulse rate -78per minute 
Respiratory rate -16per minute 
Bp -110/70
SYSTEMIC EXAMINATION :
Shape -distended 
Tenderness -no 
Palable Mass - No 
Hernial orifices -normal 
Free fluid- yes 
Liver and spleen -not palable 
DIAGNOSIS :
Low SAAG , low protein  ascites secondary to ?KOCHS ?DIABETIC  NEPHROPATHY  CERVICAL LYMPHADENOPATHY 
FNAC ON 25/6/2022 
Right  cervical LN : Chronic granulomatous Lymphadentis (probably kochi) type 2 diabetes 



 

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This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome. Name : G Maheshwari  Roll no : 44 2020 Batch 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 comeup with Diagnosis and Treatment plan General medicine case discussion CASE DISCUSSION A 45 year old female came to opd who is a farmer came with , CHEIF COMPLAINTS: Known case of
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