60 year old woman with bilateral pedal edema and shortness of breath
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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. 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.
A 60 year old woman who is a homemaker (used to be a weaver) came with complaints of pedal edema since 3months and shortness of breath since 5days
History of presenting illness
Patient was apparently asymptomatic 9years back then she felt dizziness and went to a hospital where she was diagnosed with Hypertension and Type 2 Diabetes mellitus and was kept on medication (Amlodipine and insulin 25U in the morning and 10U in the night)
3 years back she had vomiting(non projectile) and dizziness, photophobia
No history of fever, headache, neck stiffness
No history of abdominal distension, pain abdomen
Then she went to a doctor and was treated with medication(unknown)
But the symptoms did not subside(5-6 days)
Later she came here and was diagnosed with CVA and treated accordingly.
Medication given aspirin, clopidogrel A 75, betahistine
She has bilateral pedal edema (grade 3) gradual progressive till thigh since 3months
She also has shortness of breath (grade 4) associated with sweating and palpitations.
There has been decreased urinary output for 5 days and lower backache
Then she went to a local hospital and treatment was given but symptoms didnot get relieved so she was referred to a higher center, there on investigations pericardial effusion and grade 2 RPC changes were found
Past history
No history of similar complaints in the past
She is a known case of Diabetes, hypertension since 9 years, CVA
No history of asthma, tuberculosis, thyroid disorders, CAD
Personal history
Patient wakes up at 6am in the morning does household work, have breakfast at 9am and takes rest and have her lunch at 2pm and have dinner at 8pm and sleeps at 9.30 pm
She used to have alcohol before 9years
Family history:
Not significant
General examination
Patient is conscious, coherent and cooperative
She is well built and well nourished
Pallor is present
Bilateral pedal edema(pitting type)
Vitals
Temperature: Afebrile
Pulse rate: 90bpm
Respiratory rate: 25cpm
Blood pressure: 140/80 mm of Hg
Systemic examination
Per abdomen
Soft, non tender
No organomegaly
On auscultation bowel sounds heard
Cardiovascular system
S1, S2 heart sounds heard and no murmurs heard
Respiratory system
Bilateral air entry present, normal vesicular breath sounds heard
Central nervous system
Higher mental functions intact
No focal neurological deficits
Provisional diagnosis
Chronic renal failure with Diabetes mellitus, Hypertension
Investigations
On 27/12/2022
On 29/12/2022
On 30/12/2022
Treatment
Inj.LASIX 40mg IV TID
Tab.NODOSIS 500mg PO BD
Tab.AMLONG 5mg PO BD
Inj.HAI SC
Tab.CLOPITAB A 75
Tab.SHELCAL PO OD
Tab.OROFER XT PO OD
Cap.BIO D3 PO OD
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