47 YEAR OLD FEMALE PATIENT WITH PEDAL EDEMA AND ABDOMINAL DISTENTION

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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.

AFEEFA FARZANA ,8th SEMESTER

Roll no:09

This is a case of 47 year old female patient resident of narketpally came to OPD with

CHIEF COMPLAINTS:

 PEDAL EDEMA SINCE 2 MONTHS

ABDOMINAL DISTENTION SINCE 2 MONTHS 

SHORTNESS OF BREATH SINCE 2 MONTHS

HISTORY OF PRESENTING ILLNESS:

SEQUENCE OF EVENTS: sequen

patient was apparently asympotomatic 2 months back then she developed pedal edema bilaterally which was insidious onset gradually progressive to current state it is pitting type extending from foot to hip 

abdominal distension since 2 months which is diffuse,nontendor for which she went to local hospital and was diagnosed as a case of diabetic nephropathy ,Hypertension,Hypothyroidism and she was put on conservative management but her abdominal distension didnot revert back so she came to our hospital 

DAILY ROUTINE:

She is a housewife and she wakes up at 5AM freshen up ,prepares breakfast and eats breakfast at 9AM after having breakfast she does her household chores like washing clothes,cleaning,watching television,and takes nap after meal for 2 hours daily and prepare dinner,eat and sleep at 9pm.

PAST HISTORY: 

known case of diabetes since 6years 

known case of Hypertension since 2months

Known case of hypothyroidism since 2 months

PERSONAL HISTORY: 

Diet:mixed 

Appetite:decreased

bowel  and bladder: regular

sleep:adequate

No addictions 

Family history:

Not significant

Treatment history:

GENERAL EXAMINATION 

Patient was consious,coherent,cooperative.

Moderatly built and Moderately nourished

well oriented to time,place and person

pallor: present

Icterus: absent 

clubbing: absent

cyanosis:absent

lymphadenopathy: cervical lymphadenopathy present

Edema : bilateral edema is present from toes to hip. 

VITALS: 

BP: 150/90 mmHg

PR- 90 bpm

RR- 16cpm

spo2- 

GRBS: 290 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard no murmurs

Respiratory: bilateral air entry present 

per abdomem-soft and non-tendor ,distended

CNS examination

HIGHER MENTAL FUNCTIONS:

Conscious, coherent, cooperative

Appearence and behaviour:

Emotionally stable

Recent,immediate, remote memory intact

Speech: comprehension normal, fluency normal

CRANIAL NERVE:

All cranial nerves functions intact

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,presure- intact in all limbs

Posterior column:

Fine touch, vibration and proprioception are intact

MOTOR SYSTEM : 

                      Right          Left

Bulk: 

Inspection.      N.              N

Palpation.        N.             N

Tone: 

UL.                  N.               N

LL.                    N.             N

REFLEXES

 

         B      T      S      K        A         P

 

R      2+     -     -       -          -         Flexor

 

L       2+     -     -       -          -         Flexor

CEREBELLUM:

INVESTIGATIONS

p

PROVISIONAL DIAGNOSIS

 Diabetic nephropathy,ascites under evaluation