50 F with SOB , 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.


A 50 year old female from nalgonda ,farmer by occupation has come with chief complaints of
• SOB since 15 days
• Pedal edema  since 15 days

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years back when she developed SOB grade 2 and pedal edema which then extended to face and body causing generalised edema .
She then 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.
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 ,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
7 days after this she developed SOB grade 3).
She also complains of fever for 3 days and cough after treatment started here.


PAST HISTORY
Hypertensive since 6 months and is not on medication
Not a k/c/o Diabetes, Epilepsy,  Tuberculosis.

TREATMENT HISTORY
Not significant

PERSONAL HISTORY
Daily routine :
Wakes up at 6AM
Does household work
Breakfast
Goes to work at 9AM
Lunch at 1 PM
Returns at 5 PM
Does hosuehold work
Eats at 8PM
Sleeps at 9 or 10 PM


Diet: mixed
Appetite: decreased
Bowel and bladder movements :regular
Sleep -decreased/ disturbed
Addictions :none

GENERAL EXAMINATION
Patient is conscious, coherent and cooperative
Well oriented to time place person
Moderately built and nourished

No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
Edema : bilateral pedal edema

VITALS
BP 140/80 mmhg
PR 92bpm
RR 18cpm
TEMP febrile
SP02 97%
GRBS 99mg%



SYSTEMIC EXAMINATION
RS : NVBS ,BAE+, crepts
CVS: S1 S2 +
CNS: NFD
PA: soft, non tender, hepatomegaly

INVESTIGATIONS
Random blood sugar-91mg/dl (16/7/22)
anti HCV antibodies rapid-non reactive















 


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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