short case: 50 year old female patient with pedal oedema and loin pain

This is an online e-log book to discuss our patients de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Chief complaint:
A 50 year old female patient came 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 and extending upto feet  since one 1 month
Facial puffiness and 
Decreased urine output since 1 month


No history of fever

HISTORY OF PAST ILLNESS:
No history of diabetes, Asthma, epilepsy ,hypertension ,CAD.
Usage of NSAIDS  since 1 year
Denovo hypertension 
PERSONAL HISTORY:
Diet - mixed
Appetite lost
Bowel movements regular 
Bladder movements normal 
Sleep inadequate 
No known allergy

FAMILY HISTORY: No known relevant family history.

GENERAL EXAMINATION:
Patient is conscious, coherent , co-iperative and well oriented to place, person and time.

Physical examination:
Pallor : present


Icterus :no
Cyanosis :no
Clubbing of fingers: no
Lymphadenopathy: no
Vitals:
Temperature : Afebrile 
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 .
Auscultation:
Cardiac rate-92beats per min
No cardiac murmurs

Respiratory system:

Inspection: 
bilateral symmetrical,
Trachea :central
No scars , sinuses or visible pulsations.
Palpation : all inspectory findings are confirmed.
No local raise of temperature.
No tenderness.
Dyspnea :no
Wheezing: no
Percussion:
Resonant sound Is heard
Ascultation:Breath sounds vesicular

Abdominal examination:
Inspection:
Shape of abdomen :obese 
Umbilicus : central 
No scars are visible.
Tenderness :no
Palpable masses: no 
Free fluid: no 
No organomegaly.
No sinuses

Palpation:
No palpable liver
No palpable spleen
Bowel movements : regular
Auscultation: Bowel sounds heard

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: pallor

Generalized attrition
Plaque : present
Calculus: present
Teeth rotations are present
Spacing : present 


PROVISIONAL DIAGNOSIS:
Chronic kidney failure 
Anaemia

Investigations:
2D echo
 Complete blood picture:
chest x-ray 

serum creatinine and electrolytes:
Random blood sugar:
 
 

ECG
TREATMENT:
Inj furosemide:40 mg/ IV/Tid
Tab Sodium carbonate (nodosis)-500 mg/Po/Tid
Tab NICARDIA- 10 mg/PO/Tid
Tab shelcal-500 mg/PO/OD
Cap bion-3 PO/OD
Inj pantop- 40 mg/iv /OD
Inj erythropoietin 4000Iusc weekly once
Inj iron sucrose-100mg /Iv/100 ml weekly once.
Dialysis 


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