36 y/o woman with massive pericardial effusion

Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians 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 E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.

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. 


Patient came to the OPD with chief complaints of generalised swelling of body since 3 to 4 months, shortness of breath since 4 months. 



History of presenting illness : Pt was apparently alright 4 months back then she developed swelling of both lower limbs gradually progressive extending upto knee - pitting type. Gradually swelling developed on both upper limbs and also leading to facial puffiness and abdominal distension. 

C/o shortness of breath since 4 months initially grade 2 now progressed to grade 3 relieved by taking rest and aggravated on walking/ excessive talking. Orthopnea +, no pnd 

C/o abdominal distension since 4 months gradually progressive 

C/o decreased urine output since 4 months 

Sob is associated with left sided chest pain 

No c/o giddiness, sweating, palpitations 

No c/o fever, nausea, vomitings, pain abdomen, burning micturition 


Past history : k/c/o DM since 12 yrs (developed it during her 5th month of pregnancy)now using INJ H.Mixtard 10U OD (night) and T.Glimi 2mg+T.Metformin 5mg OD 

H/o PTB 20yrs back - used ATT for 6 months and stopped 

Not a k/c/o HTN, CVA, CAD, epilepsy, thyroid disorders and bronchial asthma 

Ulcer over left foot since 2 weeks 

H/o blood transfusion 1.5 yrs back, no reaction 

Surgical history - h/o lt lung lobectomy 1.5 yrs back 


Personal history : she is a housewife 

Appetite - decreased since 4 months 

Diet - mixed 

Sleep- inadequate 

Bowel - constipation + since 4 months 

Bladder - decreased output since 4 months 

No addictions 


Family history : no significant family history 


Menstrual history : irregular menstrual cycles since 5 to 6 months; amenorrhea since 5 months 


Vitals : 

Temp - afebrile 

BP - 130/80 mm hg 

PR - 84 bpm 

RR - 22 cpm 

sPO2 - 90 % at RA 

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