60 yr old female with pedal oedema and decreased urine output

June 07,2021

Name ; pebbeti ramya reddy 

Roll no;105.

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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-log book also reflects my patient centred online learning portfolio and your valuable inputs on 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 diagnosis and treatment plan

Following is the view of my case :

CASE PRESENTATION;

Date of admission;4/6/2021

A 60 year old female, agriculture labourer by occupation came to the OPD with 

#Chief complaints of ;

•PEDAL OEDEMA  since 3 days 

• DECREASED URINE OUTPUT since 3 days

•C/o vomiting and loose stools 5 days ago which has been lasted for 3 days and now subsided. 

#HOPI;

   patient was apparently asymptomatic 3  days ago then she noticed  pedal oedema

Which is of insidious in onset , gradual in progression (now generalized oedema i. e., ANASARCA)  and it is PITTING TYPE. 

Decreased urine output since 3 days , and there is no H/O burning Micturition and pain abdomen

 

She also complained of vomiting 5 days ago, the content of vomit being food, 2 episodes per day and lasted for 3 days. 

H/O loose stools 5 days ago, 5 episodes per day and lasted for one day, non foul smelling.

RAT  was done and it is negative. 

2 months back;

She gives H/O  high grade FEVER, DRY COUGH, SOB ( grade -3 , acc to NYHA)  for which she has been admitted in govt hospital in HYD.  And diagnosed as:

* BILATERAL PNUEMONITIS  with TYPE 1 RESPIRATORY FAILURE? 

*ILD? 

*RIGHT HEART FAILURE (COR PULMONALE)? 

 

Patient's record at govt hospital;



Radiology findings;

#Past history;

H/O seasonal SOB (grade 3) since 15 years, which is more during winter(10_15 episodes per yr) usually subsides on  using inhalers

 -- No h/O DM, HTN, TB, EPILEPSY. 

#personal History:

• Diet; mixed

•appetite : normal

• bowel and bladder: regular

•sleep : adequate

•No addictions

#Family history ; 

  -Not significant. 

 @In our hospital, after admission:

#General examination;

   Patient was conscious, coherent, cooperative

She is obese but moderately nourished

*vitals;

BP;130/80

PR;83 bpm

RR;18

Temp;97.5 F

Spo2; 85%on room air 

*pallor-absent

*Icterus: absent

*Clubbing: absent

*Lymphadenopathy:absent

*Edema ; present(pitting type) 

 

PITTING OEDEMA;

On examination ; her skin shows the following

# systemic examination;

*CVS; S1, S2 heard

*RS; BAE+, right IMA, IAA crepitus. 

*p/A:No tenderness, non palpable liver, spleen

*CNS:intact

#Investigations; (on 4/6/21) 

USG- ABDOMEN;

2D- ECHO;

ECG;

Chest x- ray;

**UPDATES;

--FEVER CHART ;as of now from5/6/21 to 10/6/21

--HRCT ;( on 7/6/21) 

#INVESTIGATIONS ON 10/6/21;

 *CBP;

 *RFT;

#Treatment history;

She is on dialysis in our hospital:

* session 1 -on 6/6/21 night

*session 2  -on 7/6/21 started around 11 a.m.

*session 3  - on 9/6/21

 *  THANK YOU - to dept of GENERAL MEDICINE