Short case: A 50 yr old patient with pedal oedema and loin pain
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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.
Chief complaint:
A 50 year old female patient who is resident of athmakur mandal suryapet district and home maker came to the casuality with cheif complaint of loin pain since 1 year and pedal edema since 1 month.
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 1 year back then she developed pain in the loin region since 1 year, which was gradually progressive,non radiating, has no relieving and aggravating factors. Then she developed bilateral pedal edema which is pitting type since 1 month
No history of fever
HISTORY OF PAST ILLNESS:
N/k/c/o diabetes, Asthma, epilepsy ,hypertension ,CAD.
Usage of NSAIDS more than 2 years
denovo hypertension due to usage of NSAIDS more than 2 years.
PERSONAL HISTORY:
Married
Appetite lost
Sleep is inadequate
Diet mixed
Bowel movements regular
Bladder movements normal
No known allergy
FAMILY HISTORY: No known relevant family history.
GENERAL EXAMINATION:
Patient is conscious, coherent , co-iperative and well oriented to place, person and time.
Physical examination:
Pallor : present
Icterus :no
Cyanosis :no
Clubbing of fingers: no
Lymphadenopathy: no
Vitals:
Temperature :98 F
Pulse rate: 92 beats per minute
Respiratory rate :16 cpm
Blood pressure: 160/100mmhg
SYSTEMIC EXAMINATION:
Cardiovascular system:
Inspection: elliptical and bilateral symmetrical chest,
No visible engorged veins, scars and sinuses on the chest
Palpation:
Thrills : No
Cardiac murmurs :No
Cardiac sounds s1 s2 heard.
Apex beat palpable at 5 th intercostal space medial to mid clavicular line .
Respiratory system:
Inspection:
bilateral symmetrical,
Trachea :central
No scars , sinuses or visible pulsations,
Suprasternal and supra clavicular notching is present.
Palpation : all inspectory findings are confirmed.
No local raise of temperature.
No tenderness.
Dyspnea :no
Wheezing: no
Ascultation:Breath sounds vesicular
Abdominal examination:
Inspection:
Shape of abdomen :obese
Umbilicus : central and inverted
No scars are visible.
Tenderness :no
Palpable masses: no
Free fluid: no
No organomegaly.
No sinuses
Palpation:
No palpable liver
No palpable spleen
Bowel movements : regular
Central nervous system:
Patient is conscious and speech is normal.
No neck stiffness
No meningial signs,
Sensory system: normal
Motor system :normal
Oral examination:
Tongue: pallor
Generalized attrition
Plaque : present
Calculus: present
Teeth rotations are present
Spacing : present
PROVISIONAL DIAGNOSIS:
Chronic kidney failure
Anaemia
Investigations:
TREATMENT:
Inj furosemide:40 mg/ IV/Tid
Tab Sodium carbonate (nodosis)-500 mg/Po/Tid
Tab NICARDIA- 10 mg/PO/Tid
Tab shelcal-500 mg/PO/OD
Cap bion-3 PO/OD
Inj pantop- 40 mg/iv /OD
Inj erythropoietin 4000Iusc weekly once
Inj iron sucrose-100mg /Iv/100 ml weekly once.
Dialysis
