A 50 year old patient with loin pain and pedal edema

A 50 year old female patient with loin pain and pedal edema

January 18, 2023

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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.

CHEIF 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-operative and well oriented to place, person and time.

Physical examination:

Pallor : present

Icterus :no

Cyanosis :no

Clubbing of fingers: no

Lymphadenopathy: no

Malnutrition :no

Dehydration: 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 is 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.

Dysponea :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:

Liver not palpable

Spleen not palpable

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 is pallor

Generalised attrition 

Calculus present 

Plaque present

Teeth rotation

Spacings present in between the teeth(diastema)

PROVISIONAL DIAGNOSIS:

Chronic kidney failure 

Anaemia

INVESTIGATIONS:

Chest x ray

2D echo:

 ECG

TREATMENT:

Inj furosemide-40mg/IV/TID

Tab Sodium carbonate (nodosis)-500mgPo/TID

Tab NICARDIA-10mgPo/TID

Tab shelcal--500mgPo/OD

Inj PAN-40mg IV/OD

Cap biod-3po/OD

Inj erythropoietin-4000IUSC

Inj iron sucrose-100mg/IV/100mlweekly once

Dialysis