A 70 year old female with loin pain and pedal edema
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This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 treatment plan.
A 70 year old female resident of Suryapet who is a farmer by occupation came to OPD with
CHIEF COMPLAINTS:
Loin pain since 1 year
H/o fever since 7days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back then she developed right sided loin pain which is insidious in onset and gradually progressive in nature with no aggravating and relieving factors.She also has a h/o bilateral pedal edema since 7 days which is pitting type.
She has h/o intermittent fever associated with chills
She also has h/o SOB since 3yrs which has now progressed to 4th grade
Vomitings since 3 months -2 episodes per day ,non projectile and non bilious with food as content.
No h/o burning micturition,facial puffiness.
PAST HISTORY:
No similar complaints in past
K/c/o HTN
N/k/c/o HTN,DM,epilepsy,TB,CAD
H/o NSAIDs abuse since 2 years for loin pain
H/o head injury 4 years back for which she was treated or underwent surgery.
PERSONAL HISTORY:
Diet:mixed
Appetite: decreased
Bowel and bladder movements :regular
Sleep: adequate
No addictions
FAMILY HISTORY:
No significant family history
DRUG HISTORY:
Use of NSAIDs for 2 years for loin pain
GENERAL EXAMINATION:
Patient is conscious ,coherent and cooperative
Moderately built and nourished
Pallor :absent
Icterus:absent
Cyanosis:absent
Clubbing:absent
Lymphadenopathy:absent
Edema :present
VITALS:
Temperature:98.6*F
BP:110/80mm Hg
Pulse rate:70bpm
Respiratory rate:16cpm
SYSTEMIC EXAMINATION:
CVS examination:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Per Abdominal examination:bowel sounds heard
CNS :
No focal neurological disorder found
Normal speech
LOCAL EXAMINATION:
PROVISIONAL DIAGNOSIS:
TREATMENT:
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