65 year old female came with pedal edema and easy fatigability
65 year old female came with pedal edema and easy fatigability
March 30, 2022
A Case of 65year Old Female with pedal edema and easy fatigability
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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 a diagnosis and treatment plan.
V.sai jaya krishna, Roll No.: 137
A 65 year old female homemaker resident of miryalaguda came with chief complaint of pedal edema and easy fatigability
History of present illness:
Patient was apparently asymptomatic 15 days back when she developed pain and swelling in the leg which was sudden in onset gradually progressive which aggrevated on exercise and relieved with rest.
She was able to walk initially but 13 days back she suffered from aggravated pain in the legs and wasn't able to walk anymore without support.
She was suffering from pedal edema since 15 days.
During that time she also developed facial puffiness and swelling in hands since 13 days.
She complained of shortness of breath since 5 days (grade IV MMRC).
No history cough and chest pain.
No history of burning micturation, hematuria and fever.
Past history :
Patient is known case of Hypertension since 15 years for which she is under medication.
Patient is known case of Diabetes since 15 years for which she is under medication.
Patient fell down on her left arm and fractured it 2 months ago for which she underwent ayurvedic treatment.
No history of Bronchial asthma,TB , Epilepsy.
Personal history:
Her appetite is reduced since 5 days
She takes a mixed diet
Her bowel and bladder movements are regular
Sleep is prolonged
Urine output is reduced
No known allergies
No known addictions
Family history:
Her elder brother passed away in a heart attack at the age of 40 years old.
Her younger brother is a known case of diabetes
No history of any renal problems
General examination:
Patient is conscious, coherent and coperative well built and well nourished.
Vitals:
Temperature: Afebrilei
Pulse rate: 90 bpm
Respiratory rate: 18 cpm
Bp: 140 /90 mmhg
Spo2: 99%in room air
O/E:
Pallor : present
No icterus
No cyanosis
No clubbing
No koilonchya
No lymphadenopathies
Pedal edema: pitting type present
Clinical pictures:
Systematic Examination:
-CVS:
S1 and S2 are heard
no thrills and no murmurs were heard
-Respiratory:
vesicular breath sounds heard
trachea is in central position
no wheezing
no Dyspnoea
-Abdomen:
no tenderness
no palpable mass
no hernial orifices
no free fluid
liver and spleen are not palpable
bowel sounds are heard
-CNS:
Conscious and slurred speech
normal gait
crainial nerves are normal
sensory system is normal
motor system is normal
INVESTIGATIONS:
UltraSonoGraphy:
B/L grade I RPD
Provisional Diagnosis:
This is a case of Chronic Renal Failure associated with Diabetes.
