General Medicine case 4;

 25.C.Ruchitha Reddy

October 12 2021.

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A 15 year old female,studied till 5 the class currently working as a daily wage worker, came to casualty with chief complaints of;

1)Bilateral lower limb edema since 15 days

2)Reduced urine  output since 10 days

3)Abdominal distension since 5 days

4) Facial puffiness since 3 days 

5)Nonproductive cough since 3 days

HISTORY OF PRESENT ILLNESS;

Patient was apparently asymptomatic 15 days ago later she developed 

a swelling in the vaginal region which was insidious in onset and gradually  increasing in size, This was diagnosed as Bartholin cyst for which incision and drainage was done.

H/O fever since 1 day

Dyspnea on rest since 2 days

No H/O Burning micturation ,white discharge

PAST HISTORY;

H/O of pneumonia when she was 5 years old.

PERSONAL HISTORY;

Appetite-lost

Sleep -Adequate

Bowel movements-Regular

Micturation - normal

No addictions

No known allergies.

FAMILY HISTORY;

No significant family history

GENERAL EXAMINATION;

Patient is conscious,coherent ,cooperative and well oriented to time,place and person.

Pallor - yes

Edema -present

Abdominal stiffness - present

No Icterus ,cyanosis,clubbing of fingers, lymphadenopathy.

Temperature 98.6F

Pulse rate-102/min

Respiratory rate - 26 cycles /min

BP-120/80 mmHg

SYSTEMIC EXAMINATION;

CVS-S1,S2 heard

Respiratory System - Dyspnea present

Abdomen - soft, tender

CNS -speech normal

Menstrual history - Regular

INVESTIGATIONS;