Y4-History Taking Session -Medical Placement I – W3

Case scenario No. 4- Lower Limb swelling

History Data
Personal Data:
Name: Mohanad/Safaa Male/Female patient Age: 60-Year-old
Occupation: teacher Residence: Live in Al Medina,
Setting: Patient came to OPD.
Reason of consultation (Chief Complaint):
- Worsening lower extremities swelling for 4 weeks duration

Detail Description for fulfilling the History of present illness:

- The condition started four weeks ago and got worse during the last two weeks.
- He describes it as bilateral symmetrical swelling.

Other relevant Symptoms (Pertinent positive and negative symptoms)

- His Leg swelling is associated with exertional shortness of breath and
shortness of breath when he is laying flat.
- He also reports palpitation, dizziness, but denies syncope.
- No GIT manifestations suggestive of chronic liver diseases
- No urinary manifestations

Review of Systems:

Respiratory: Denies productive cough.

CNS: Occasional headache otherwise unremarkable

Musculoskeletal System: Unremarkable

Skin: No skin rash, ecchymosis, or bleeding tendency.

Y4-History Taking Session -Medical Placement I – W3

Past medical history:

— - DM and hypertension
- No history of chronic drug intake, allergy.

Family history:
— - Patient father had weak heart.
Social history:
— - He/she live with his/her family and have a good social life.
— - He/she is a heavy cigarette smoker about 2 packs for 20 years
Patient’s perspectives
- Leg swelling annoys you at work because your feet doesn’t fit.
- You want doctor to give you any medication to improve your shortness of
breath and Leg swelling.
- You are afraid it might be something serious as one of your relatives had
similar condition that died due to this condition.
 From the history Data … What's your provisional diagnosis ? Why? (Explain
important history data supporting your hypothesis)
 From the history Data …. What's your Differential Diagnosis? (Explain defining and
discriminating features of each diagnosis?

Differential Diagnosis
Biventricular heart failure:

1. Valvular disease
2. Acute myocarditis
3. Ischemia
4. Congintal disease
Constrictive pericarditis/effusion:

pulmonary hypertension
Y4-History Taking Session -Medical Placement I – W3

Renal failure excluded in this senario

Cirrhosis excluded in this senario