43 year old female with Pedal Edema, Generalised Weakness.
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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.
43 year old female resident of Narketpally came to OPD with chief complaints of
Swelling in bilateral lower limbs upto ankle since 15 days
Generalised weakness since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 days ago. She noticed swelling in her both lower limbs until ankle , insidious in onset , gradually progressive in nature , Pitting type . No aggravating and relieving factors.
H/o generalised weakness since 1 week.
Increased menstrual bleeding since 3 months but duration remained same not associated with clots .
No h/o orthopnea and paroxysmal nocturnal dyspnea.
No h/o decreased urine output, burning micturition .
No H/o nocturia, polyuria
No H/o nausea, vomiting, loose stools, constipation.
No H/o fever, cough ,cold .
No H/o palpitations, sweating .
No H/O chest pain.
No H/o abdominal distension, abdominal pain.
No H/o hematuria.
No h/o headache,sleep disturbances.
PAST HISTORY: She is a 43 year old lady who was born as an elder daughter in her family completed her education until 10th standard.She has two younger brothers.
At the age of 15 she got married and started living with her husband
In 1995 ,she gave birth to her 1st child (male ) but died after 3 days.(NVD)
In 1997 ,she gave birth to a girl child who died at the age of 6.(NVD)
Later with spacing of 3 years she gave birth to her 3rd child who is currently pursuing degree .(NVD )
In 2002 , she gave birth to her 4th child who is a boy . (NVD)
In 2004, she gave birth to her 5th child who is a boy . (NVD)
After 9 months of birth of her 5th child, she had suffered from low back pain , itching in vaginal area for which she visited her gynaecologist,got evaluated.Her doctor told her that she has lesion in her uterus and got treated for it .
There were no symptoms related to it until 2019 ,but in 2019 when she noticed intermenstrual bleeding for 2 months she visited her gynaecologist and took medication.
4 years ago , patient had complaints of generalised weakness and visited her local doctor , blood investigations were done and her Hemoglobin was around 6 gm/dl .
So she took iron and folic acid supplements for a month and stopped.
On June 7 2023 , patient came with similar complaints to our OPD , investigations like complete blood picture,serum electrolytes , creatinine and blood urea were done and was advised to get admitted but she wasn't willing to get admitted.
Not a k/c/o Diabetes Mellitus, Hypertension, Tuberculosis,CAD, Thyroid disorders.
MENSTRUAL HISTORY:
Menarche - 13 years
28/5 - regular periods
Earlier 2- 3 pads / day
Not associated with clots .
Since 3 months increased bleeding during periods , duration remained same
Pads / day - 4 pads / day ( wholly filled)
PERSONAL HISTORY:
Diet - mixed
Breakfast - 4 Idly / 3 dosa with chutney / 2chapathi with curry / upma
Lunch - 1 cup rice with vegetable curry ( tomato ,potato , okra, bottle guard )
Dinner - 1 cup rice with vegetable curry,curd rice
Consumes meat twice or thrice a month .
Daily intake in Calories (avg)
Tea with milk and sugar - 45 cal
Idli (1) - 135 cal
Chutney - 331 cal
Rice -130 cal
Vegetable curry - 85 cal
Curd - 118 cal
On avg total intake is 1582 cal
Deficient - 418 cal
Sleep - Adequate
Appetite - normal
Bowel and bladder - regular
No addictions
No allergies
DAILY ROUTINE :
Earlier patient used to wake up by 6 am ,do her household work ,drunk tea at 7 am eat breakfast by 9 am and go and sit in her general store to look after.later at 1 pm she takes rice with any type of curry ( mostly Vegetables - takes meat once in a week - occasionally) . Again she will go and work in her shop.she works until 9 and leaves the other pending work to her children.she goes home and prepare food . She will have dinner by 10 pm ( some times by 11 pm ) . She will go to bed by 12 in the night .
After she noticed pedal edema , she stopped sitting for long time as she thought that was the cause for it. Because of difficulty in breathing and generalised weakness, she stopped going to her general store and taking rest at home.
FAMILY HISTORY:
No significant history
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
She is moderately built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
On examination,edema is present below knee level
Vitals :
Temperature - 96.8 ° F
Blood Pressure -110/70 mmHg
Pulse Rate -89 bpm
Respiratory Rate - 16 cpm
SYSTEMIC EXAMINATION:
Per abdomen:-
On inspection
Shape of abdomen : flat
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver is not palpable
Spleen is not palpable
On percussion
Resonance note heard
On auscultation
Bowel sounds heard
CVS Examination:
Inspection
No raised JVP
Trachea appears to be central
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Palpation-
Trachea Central in position
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
Auscultation-
S1 and S2 heard, no murmurs heard
Respiratory Examination:
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
CNS Examination:
Conscious
Normal speech.
No neurological deficit found.
PROVISIONAL DIAGNOSIS:
Anemia under evaluation
Nutritional? Menstrual blood loss?
INVESTIGATIONS:
7 June 2023 .
Complete Blood picture:-
USG report
Positive findings - borderline splenomegaly
Right renal calculi
ECG
Heart rate -100 bpm ( tachycardia)
Normal sinus rhythm
Normal axis
On 13 June 2023
Hb- 5gm/dl
TLC - 5800
MCV - 61.7
MCHC - 23.1
MCH - 14.3
Platelet - 3.0
Serum iron - 31 micro gram / dl
Blood urea - 22 mg/dl
Serum creatinine - 0.6 mg/ dl
Blood grouping - B +ve
Serum ferritin -
Liver function tests :
Chest x-ray
Fasting Blood sugar -285 mg/dl
FINAL DIAGNOSIS:
Severe Anemia Nutritional? Menorrhagia?
Denovo Diabetes mellitus
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