21 year female with fatiguability and SOB
, I am bandaru chetan 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This elog also reflects my patient centered online learning portfolio
I have 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
Chief complaints
21 year female came to the casuality with the Chief complaints of easy fatiguability and shortnes
s of breath since 7 years
Full body swellings since 15days
History of presenting illness
Patient was apparently asymptomatic 7 years back
Then she developed fatiguability and shortness of breath
SOB was insidious in onset gradually progressive and she complaints of occasional orthopnea
She had an episode of sob and anasarca 15 days back then she visited a local dermatologist and took medications
She had a similar episode 3 days back and then she came to our hospital for further evaluation
N/H/O fever, burning micturition, vomitings or loose stools
N/H/O numbness or any tingling sensation
History of past illness
H/O neurofibromatosis 10yrs back
H/O blood transfusion 3yrs back and when she was 9 yrs old
Not a known case of DM, HTN, TB, Epilepsy, Asthma.
Treatment history
No significant treatment history
Personal history
Single
Degree student
Normal appetite
Mixed diet
Normal Bowel sounds
Normal micturition
No known allergies or addictions
Family history
Her mother also has neurofibromatosis since 21 years
Menstrual history
Menarche - 12 years
LMP - 13th June
Menstrual cycle - 4/30
General examination
Pallor
no icterus, cyanosis, clubbing of fingers, lymohadenopathy, pedal odema
