A 65 year old woman presented with shortness of breath and pedal edema.
August 16 , 2022
5 urine
Hi , Iam Princy rose ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios.
A 65 year old woman farmer by occupation came to causality with complaints of shortness of breath and pedal edema.
CHEIF COMPLAINTS :
> SOB for last 4 days
> Cough for last 4 days
> Pedal edema for last 4 days
> Pain in lower limb for last 4 days
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 4 months back. In April , She had SOB on exertion with tingling sensation in both upper and lower limbs, pedal edema and decrease in urine output ( creatinine : 3.1mg/dl ) for which she got treated in local hospital and her symptoms got relieved.
She had nausea , vomiting ,weakness ,burning micturition and pain in lower limb (creatinine : 3.8mg/dl uric acid:5.6mg/dl) again by end of June for which she was treated and all her complains got relieved .
In July she presented with pain in lower limbs ( creatinine : 5.2mg/dl uric acid:6.4mg/dl)for which she got treated and symptoms got relieved.
In mid of august she came to our hospital with complaints of SOB for past 4 days which is of grade II . It is associated with cough with expectorant. She is also having pain in both lower limb from knee to toes only on movement for past 4 days. Pain is of non radiating type.
She works as a cotton picker and experience pain even in bending down to pick cottons.
No redness and tenderness present at or around joints.
Not having fever
No abdominal pain
No back ache.
HISTORY OF PAST ILLNESS:
> k /c / o hypertension since 8 years
No diabetes,
No asthma
No history of tuberculosis
No history of epilepsy.
DRUG HISTORY:
> Tab Atenolol 50 mg OD for HTN for last 8 yrs
PERSONAL HISTORY:
> Occupation : Farmer
>Patient is married
>Patient takes mixed diet but has a decreased appetite.
>Bowel and bladder movement is normal and regular
>No addiction .
FAMILY HISTORY :
No significant familial history.
GENERAL EXAMINATION
>Pallor : Present
>Icterus : Not seen
>Cyanosis : Not seen
>Clubbing : Not seen
>Lymphadenopathy : Not seen
>Edema : B/L Pedal edema Seen
VITALS
>Temperature : 98.3℉
>PR : 76 beats per minute
>BP : 130/80 mm of Hg
>RR : 18 cycles per minute
>SpO2 : 97% in room air
>Blood Sugar (random) : 119mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
>s1 and s2 heard
>Thrills absent.,
>No cardiac murmurs
RESPIRATORY SYSTEM
>Normal vesicular breath sounds heard.
>Bilateral air entry present
>Trachea is in midline
ABDOMINAL EXAMINATION
INSPECTION
>Shape - Scaphoid
>Equal movements in all the quadrants.
>No visible pulsation, dilated veins and localized swellings.
PALPATION
>No tenderness
>No palpable mass
CENTRAL NERVOUS SYSTEM EXAMINATION
>Conscious and coherent
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE
INVESTIGATIONS:
DAY 1 -
1, Complete blood picture
2, RFT
Blood urea:
Creatinine :
3, USG abdomen
4, random blood sugar
TREATMENT :
1) TAB. NICARDIA PO/OD
2)TAB NODOSIS
3)TAB SHELCAL 500mg PO/OD
4)TAB OROFER XT PO/OD
5)CAP BI0 D3 PO/OD WEEKLY ONCE
6)INJ. ERYTHROOIETIN 4000IU S/C TWICE WEEKLY
DAY 2 :
Patient condition not improved
Further investigations :
ECG:
HBsAg- RAPID
HIV 1/2 Rapid test
Anti HCV antibodies
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