13 year old girl with b/l pedal edema

 This is an online e log book to discuss our patient 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 centered 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 plan.


DEMOGRAPHIC PROFILE AND CHEIF COMPLAINTS...
My case is a 13years old girl who is a student  by occupation studying in hostel located at annaram,came with  the cheif complaints complaints of  Bilateral lower limb swelling since 10days and facial edema since 8days.

HISTORY OF PRESENTING ILLNESS.....

Patient was apparantly asymptomatic 2months back and then she developed nausea and vomitings 4 to 5 episodes for 3 dayscontent  of the vomiting isfood particlesand non bilious in nature andnot associated with pain abdomen.No loose stools
 since 10 days  she developed Bilateral lower limb swelling first up to ankle and then it progressed to swelling of face.

No H/o Shortness of breath,no fever,no burning micturition,no rashes on skin.

MENSTRUAL HISTORY......
History of irregular menstrual cycles since menarche (achieved her menarche at 12 years that is 8 months ago.)menstrual cycles were once in every 3 months which lasts for 5days.Last menstrual period is  30/05/2022.

PAST HISTORY.....
Not a known case of DM,HTN,EPILEPSY,  ASTHMA, TB.

FAMILY HISTORY.....
No relevant family history.

PERSONAL HISTORY......
Diet:mixed
Appetite:normal
Sleep:adequate
Bowelandbladder :Regular.
No addictions.


GENERAL EXAMINATION.....
Patient is conscious coherent and cooperative
Moderately built and moderately nourished
Well oriented to time place and person.
.Pallor present ,edema present(Bilateral pitting type of edema)
.NO icterus ,cyanosis, clubbing , lymphadenopathy.
VITALS:BP:110/60mmhg.
           RR:16cpm.
           HR:82bpm.
           Temperature:afebrile.

SYSTEMIC EXAMINATION.......

Cvs:
S1,S2 heard on auscultation and no murmurs are heard.
Cns:
No focal neurological deficits.
Rs:
Normal vesicular breath sounds and Bilateral air entry present .
PA:
No organomegaly on Palpation and abdomen is soft and non tender.

JVP not elevated.



Picture showing Bilateral pitting type of pedal edema.

                    





PROVISIONAL DIAGNOSIS:
ANASARCA DEVELOPED SECONDARY TO NEPHRITIC SYNDROME
TREATMENT:
Monitoring VITALS and adviced to drink more amount of water.

Patient was discharged wantedly .

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