A 35 year old female with Pedal edema since 20 days, Decreased urinary output since 20 days, shortness of breath, Facial puffiness.
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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.
CHIEF COMPLAINTS
A 35 year old female came to casualty with
Bilateral pedal edema since 20 days,
Decreased urinary output since 20 days,
shortness of breath, and Facial puffiness.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic until 2 months back and then she developed chest pain for which she visited local hospital in miryalguda, where she was diagnosed with chronic kidney disease and low hemoglobin, 2 PRBC transfusions were done.
After the blood transfusion, she developed bilateral pedal edema which subsided on medication.
20 days back she developed Bilateral pedal edema, Decreased urinary output, shortness of breath (orthopnea and nocturnal dyspnea).
10 days back she developed Fever not associated with chills and rigor, which subsided on taking medication.
1 PRBC transfusion was done in the Nalgonda hospital.
PAST HISTORY
Hypertensive since 2 months .
Not a known case of asthma, diabetes, TB.
PERSONAL HISTORY
Adequate diet before developing of symptoms
mixed diet
regular bowel and bladder movements
sleep adequate
no consumption of alcohol and smoking
FAMILY HISTORY
No history is seen in family
No cases of hypertension and diabetes
TREATMENT HISTORY
Previously seen by a doctor and subsided on taking medication.
PHYSICAL EXAMINATION
GENERAL
Patient is coherent, cooperative and conscious.
proper nourishment and proper build is seen.
pallor - Present
Icterus - absent
Lymphadenopathy- absent
clubbing - absent
cyanosis - absent
Pedal edema - Present
VITALS
Afebrile
BP- 170/100 mm Hg
PR-99 bpm
RR- 22 cpm
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM-shortness of breath
CVS-S1,S2 +
RR- 16cpm
Spo2 -98%
RS: BAE+
P/A: SOFT, NON TENDER
CNS- NAD
# Outside reports on 30/11/21:
On 02/12/21:
PROVINSIONAL DIAGNOSIS
Acute Kidney injury on CKD
TREATMENT:
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