A 60 yrs old female patient with Pedal oedema and SOB
January 03,2023
This is an online e-log book to discuss our patient de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
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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 coming up with diagnosis and treatment plans. is an 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 a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
CASE REPORT
A 60 years old female patient , who is a retired weaver by occupation (retired 4yrs ago) presented to OPD with
CHIEF COMPLAINTS :
- B/L Pedal oedema since 4 months
- Shortness of breath since 6 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 9 years ago , then she felt dizziness for which she went through a general check up and was diagnosed with Hypertension and Diabetes mellitus and is on medication since then.
5 years ago she had frequent episodes of dizziness which was associated with vomiting (nonprojectile) and photophobia. These episodes reccured for a duration of 5 to 6 days.
Then she visited our hospital, admitted for 6 days and discharged (diagnosis unknown) with medication : Clopidogrel 75mg , Betahistine and Aspirin.
No H/O fever, headache.
Since 3 months there is H/O Bilateral Pedal oedema which gradually progressed upto thighs.
There is H/O a shortness of breath (grade 3)since 6 days which was insidious in onset, aggravated on lying down and relieved temporarily on sitting and meditation.
No H/O cough , sputum.
H/O decreased urine output and lower backache since 5 days.
PAST HISTORY :
No similar complaints in past
H/O Diabetes since 9 yrs and Hypertension since 10 years.
Not a known case of thyroid , asthma , TB , cardiovascular disease.
TREATMENT HISTORY :
On medication for Diabetes (Inj. Human Mixtard 40IU/ml) and for hypertension (Amlodipine 5mg) ; clopidogrel , aspirin.
No H/O any surgeries in past.
No H/O any drug allergies.
PERSONAL HISTORY :
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bowel & Bladder habits - Regular ; decreased urine output.
Addictions - Occasionally alcohol 9 yrs back.
FAMILY HISTORY :
No significant family history.
GENERAL EXAMINATION
Patient is conscious, coherent and co operative well oriented to time place and person.
Well built and nourished
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - No palpable lymph nodes
Edema - Bilateral pedal oedema (pitting type).
VITALS :
Temperature - afebrile
BP - 120/80 mmHg
RR - 24 cpm
PR - 83 bpm
SYSTEMIC EXAMINATION
Respiratory system
Bilateral airway entry - present Normal vesicular breath sounds heard all over the chest.
CardioVascular System :
Apex beat not visible on inspection and is diffuse on palpation.
S1 and S2 heard.
No palpable murmurs.
Central Nervous System :
No focal neurological deficits
Speech - Normal (coherent)
Per abdomen :
No tenderness
No pain
No palpable organs
Bowel sounds - heard
PROVISIONAL DIAGNOSIS :
Chronic Kidney Disease secondary to Diabetic Nephropathy (k/c/o DM since 9 yrs and HTN since 10 yrs); with anemia ; with history of CVA.
INVESTIGATIONS :
CT BRAIN(taken before)
TREATMENT :
Inj. LASIX 40mg IV TID
Tab. NODOSIS 500mg PO BD
Tab. Amlong 5mg PO BD
Inj. HAI S.C (according to GRBS 6th hourly before meal)
Tab. CLOPITAB - A (75/20) PO
Tab. Shelcal PO OD
Tab. Orofer PO OD
Cap. BIO - D3 PO OD
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