CASE 1: A 65yr old female with pedal edema and SOB

A 65 year old female with pedal edema and shortness of breath.

Hi, I am P. Shreya Reddy , 3rd semester medical student.

This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

CASE SCENARIO 

A 65 year old woman resident of Nalgonda came to the OPD with chief complaints of
• shortness of breath since 1 week
• pedal edema since 3 months 
• back pain since 1 week 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 years back then she developed back pain, leg pain and Pedal edema bilaterally for which she went to local doctor and used unspecified medication.

Since it was not subsiding, 5 months back she went to Nalgonda hospital and was diagnosed with kidney failure .

Now 1 week ago she came with complaints of shortness of breath which is aggravated on walking and relieved on rest.

PAST HISTORY

K/C/O hypertension since 10 years on irregular unspecified medication.
N/K/C/O DM, TB, Asthma, epilepsy. 

PERSONAL HISTORY 

Married
Mixed diet
Occupation: farmer (stopped working due to back pain)
Normal appetite
Regular bowels
Normal micturition 

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative and Well oriented to time, place & person.
Moderately built and nourished.
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema- bilateral Pedal edema since 3 months, non pitting 

VITALS 
On admission 
Temperature -afebrile
BP-130/80mm Hg
Pulse Rate- 76bpm
Respiratory Rate- 16cpm 

24/8/22
Temperature- afebrile
BP- 130/70bpm
Pulse rate- 72 bpm
Respiratory rate- 16cpm 

SYSTEMIC EXAMINATION 

Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheezing 
- trachea position: central
- breath sounds: vesicular

Abdomen
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable 
- spleen: not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal

Central Nervous System
- conscious 
- normal speech
- no neck stiffness
- no Kernig's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: present 

INVESTIGATIONS
TREATMENT

Tab Nicardia 10mg PO BD
Tab nodosis 500mg PO BD
Tab shelcal 500mg PO OD
Tab orofer XT PO OD
Inj erythropoietin 4000IU SC twice weekly 
Inj Pantop p40mg IV BD
Inj zofer 04mg IV TID
Tab zincovit PO OD
Syp aristozyme 15ml PO TID 20 min before food.

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