A 45 year old female with sob and pedal edema .
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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.
A 50 year old female resident nalgonda ,farmer by occupation has come with chief complaints of
• Pedal edema since 15 days
. SOB since 10days
.fever since 7days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years back then she developed SOB which grade 2 and pedal edema which is initially at the ankle and then progressed to legs and face with in 10 to 15 days and causing generalised edema .for which she went to nalgonda hospital and used medications prescribed and the symptoms subsided.
6 months back in jan 2022 she developed the same symptoms and again went to nalgonda hospital and took medications and symptoms subsided.then on routine general examination She was also diagnosed with hypertension and is not on treatment.
Now 15 days back she had developed the same symptoms SOB grade 3 and pedal edema which was initially at the level of ankleand then became generalised edema and went to nalgonda hospital and since the symptoms were not subsiding they came to Kims.
(First she developed pedal edema which extended and caused generalised edema
5 days after this she developed SOB grade 3).
She also complains of fever for days no associated with chills and rigors and she also developed cough since 3 days after treatment started here.
PAST HISTORY
Hypertensive since 6 months earlier when she was diagnosed took medications for 1 month and then she stopped taking medicine
Not a k/c/o Diabetes, Epilepsy, Tuberculosis, thyroid
TREATMENT HISTORY
Not significant
PERSONAL HISTORY
Daily routine she wake up in the morning 6 am and get fresh up do house work and then cook food and then she will have the break fast and then she goes to farm by 9 am and then return to home by nearly 5pm and then after some time she will prepare dinner and then she will have the dinner
Diet-mixed
Appetite-decresed
Bowel and bladder movements -regular
Sleep -decreased/ disturbed
No Addictions
Mo allergy
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative
Well oriented to time ,place, person
Moderately built and nourished
Pallor-no
Icterus-no
Cyanosis-no
Clubbing-no
Lymphadenopathy -no
Edema-Bilateral pedal edema
BP 140/80 mmhg
PR 92bpm
RR 18cpm
TEMP febrile
SP02 97%
GRBS 99mg%SOB since 10days
SYSTEMIC EXAMINATION
RS : NVBS ,BAE+, crepts
CVS: S1 S2 +
CNS: NFD
PA: soft, non tender, hepatomegaly
INVESTIGATIONS
.Serum creatinine-
0.9mg/dl(on 20/7/22)
1.0mg/dl(on19/7/22)
1.8 mg/dl(18/7/22)
2.1mg/dl(16/7/22)
.Blood urea-29mg/dl(20/7/22)
42mg/dl(on19/7/22)
58mg/dl(18/7/22)
65mg/dl(16/7/22)
.T3-0.61ng/ml(normal-0.8 to 1.8)
.T4-10.24micro g/dl
.TSH-2.23micro g/ml
.prothrombin time-18 sec
INR-1.33
APTT test-35sec
.HIV1/2rapid test-non reactive
HBsAg rapid-negative
.random blood sugar-91mg/dl (16/7/22)
.anti HCV antibodies rapid-non reactive
ULTRA SOUND-
Grade 1 RPD changes
Mild ascites
Mild b/l pleural effusion
PROVISIONAL DIAGNOSIS
Cardiorenal syndrome (type II)
TREATMENT
1. Fluid restriction 1.5l/day
2. Salt restrictions <2g/day
3. Inj lasix 40mg TID
4. Tab Dolo 650mg TID
5. Inj Neomol 100ml IV SOS
6. Syrup Ascoryl 10ml TID
7. Inj Monocef IV BD
8. Vital monitoring 8th hourly
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