50 year old female with sob and pedal edema .

July 02, 2022

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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 come up with diagnosis and treatment plan.

My case is a 50 year old lady who is a labourer by occupation came form arvapalli with the

CHEIF COMPLAINTS:
Pedal edema since 4 days

sob since 2 days.

HISTORY OF PRESENTING ILLNESS:
Patient was apparently normal 1 year back then she developed joint pain in the left knee ( dragging type,continuous,aggrevates on walking and relieves on rest) for which she went to hospital and took medication accordingly and the knee pain was subsided.
.... 5 months ago she developed joint pain in the right knee and the pain increased and became severe so she visited a local hospital and there on general examination she was diagnosed as hypertensive for which she took medication for 10 days and then discontinued.
......5 days back she got pain in the chest which is not radiating type and not associated with sweating and palpitation for which she went to hospital and took an injection and the pain subsided.
......4 days back she developed pedal edema which was initially up to the ankle and then it progressed to legs and then to face so that facial puffiness is observed.and then 2 days back she developed shortness of breath grade 3 and she also complains of increased urine output and urinary urgency.

[ ] PAST HISTORY:

Not a known case of Diabetes, tb ,epilepsy ,asthma .

Known case of HTN since 5 months and took medication for 10 days and stopped it voluntarily.

[ ] FAMILY HISTORY:
Not significant.

[ ] PERSONAL HISTORY:

Daily routine:
DIET:mixed
Appetite:normal
Sleep:adequate
Bowel :Regular
Bladder:increased urination since 2 days
Addictions :no addictions.

[ ] General examination:
Patient was conscious coherent and cooperative
Well built and moderately nourished.
Well oriented to time place and person.
Pallor present, Bilateral pedal edema which is of pitting type.
icterus ,cyanosis ,clubbing and lymphadenopathy. Are absent
Vitals:
Bp:180/90
RR:22cpm
Temp:afebrile
Pulse rate:78bpm.

[ ] SYSTEMIC EXAMINATION :
CVS:S1,S2 HEARD AND NO MURMURS.

CNS:NO FOCAL NEUROLOGICAL DEFICITS

RESPIRATORY SYSTEM: BILATERAL AIR ENTRY PRESENT .
NORMAL VESICULAR BREATH SOUNDS.

PER ABDOMEN:
On inspection:
Shape :obese.
Umbilicus:inverted.
Movements of abdomen :moves with respiration.

On Palpation:
No local rise of temperature.
Hernial Orifices are normal.
Tenderness on Palpation in right lumbar region.
Liver is not palpable
Spleen is not palpable.

On auscultation:
Bowel sounds heard .
No bruits.