A 76 year old female with pedal edema
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I've 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 a diagnosis and prognosis
A 76 year old female came to the general medicine OPD with
CHIEF COMPLAINTS
Pedal edema since 4 days
Shortness of breath since 4 days
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic 4 days ago then she developed bilateral pitting type of pedal edema extending upto the knee
History of shortness of breath since 4 days
No history of chest pain and palpitations
History of loss of appetite since 4 months
No history of burning micturition
History of itching.
DAILY ROUTINE BEFORE THE ILLNESS
Patient usually wakes at 6 am and eats breakfast at 8 am and starts tailoring at 9 upto 12 30 pm and then eats lunch and takes a nap of 1 HR and then wakes up and do some house chores and then sleeps again in the evening and wakes up and do some tailoring and then eats dinner and sleep by 9 30 pm
PAST HISTORY
Known case of hypertension since 4 years
Not a known case of diabetes thyroid asthama
PERSONAL HISTORY
Mixed diet
Adequate sleep
Regular bowel and bladder habits
No addictions
No allergies
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient is conscious coherent and cooperative No signs of pallor icterus cyanosis lymphadenopathy clubbing.
Pedal edema is present which extends upto the knee
VITALS
Temperature: Afebrile
Blood pressure: 120/80mmhg
Respiratory rate: 16 cpm
Pulse rate: 88 bpm
SYSTEMIC EXAMINATIONS
GIT
Shape of the abdomen is schapoid
No tenderness
No palpable mass
CNS
No focal neurological deficit
Gait is normal
Speech normal
Signs of meningial irritation absent
All reflexes are normal
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular sounds heard
CARDIOVASCULAR SYSTEM
No murmurs
S1 and s2 heard
PROVISIONAL DIAGNOSIS
Chronic kidney disease with maintenance hemodialysis
INVESTIGATIONS
VIDEO OF GAIT
Treatment
Tab telmisartan
Tab cilnidipine
Tab sodium bicarbonate
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