A 47 year Old woman came to OPD with chief complaints of Swollen Abdomen and Swollen Legs and Shortness of Breath since 2 months

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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.

Ankur Kumar

Roll no 14

C/O

Pedal Edema 2 Months

Abdominal distension since 2 Months

Shortness of Breath since 2 Months 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back and then she developed pedal edema bilaterally which was insidious in onset and gradually progressive and it is pitting type of edema and Abdominal distension since 2 months for which she went to a hospital in nalgonda, where she was diagnosed for diabetic nephropathy , Hypertension, and Hypothyroidism.

She was administered Lasix(Furosemide) injection six times daily for 24 days

Her pedal edema subsided and she was sent home.

After 10 days at home she started developing abdominal distension and Shortness of Breath.

She then came to KIMS Narketpalli where she was admitted.

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 6 years 

Known case of Hypertension since 2 months

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

Pallor: present

Icterus: absent 

Cubbing: 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 abdomen-

Soft and Non-tendor and 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

Investigations

Diagnosis

 Ascites under evaluation, Diabetic Nephropathy,

Suspected TB.

Treatment