Case 9 - 21 year female with fatiguability and shortness of breath

                                      

 Hi, I am Yeddula Vishnu Priya, 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 shortness 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, lymphadenopathy, pedal edema

Investigations