65 year old female with B/L pedal edema

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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.

Unit 1 

DOA :27/523

A 65 yr old female ,resident of suryapet came to the opd with chief complaints

vomitings since 3 months 

swelling of both lower limbs since 1month.

HOPI:- Patient was apparently asymptomatic 3 months back. She then had vomitings (2-3 episodes/day) -on and off since 3 months

Vomitings - watery, non-projectile, non-bilious with food particles as contents and non blood stained.; Heart burn occasionally. Vomitings aggravating on after taking food .

-no c/o pain abdomen, loose stools.

C/o constipation - passes daily -hard stools or passes every alternate day

c/o swelling of bilateral lower limbs -pitting type, extending above ankle and not extending upto the knee. aggrevated on walking and relieved (incompletely) on lying down.

C/o Decreased urine output

 no h/o burning micturition, no involuntary micturition , Pt is unable to hold the urine during urge to micturition.

c/o SOB - after eating food, and after walking (Grade-II)

no c/o chest pain, palpitations, Orthopnea, PND.

c/o LBA-radiating to B/L lower limbs, no tingling sensation. c/o tingling of hands and feet.

Past history:

K/c/o Hypertension  7-years on medication.

(T. Amlodipine 5mg OD)..

Not a k/c/o TB, Epilepsy, Asthma, CVA, CAD,

Thyroid disorders.

personal history-

diet: mixed

appettite:normal

bowel and bladder: decreased urine output

sleep: adequate

no addictions

general examination:

patient is conscious,coherent, cooperative 

well oriented to time, place,person

moderatly built and nourished

vitals-

Temp: afebrile

PR :80bpm

BP :110/70 mmhg

RR :18cpm

GRBS :111mg/dl

systemic examination-

CVS:s1s2 heard,no murmurs

RS:BAE+,nvbs heard

CNS:nfnd,hmf intact

P/A:soft,non tender,no organomegaly

Investigations 

HEMOGRAM :

RBS:

RFT:

LFT:

ECG:

2D ECHO:

Moderate AR, MILD MR,MILD TR /PAH

NO RWMA,NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION,NO PE

USG findings:

1)E/o multiple hypoechoic foci noted in gall bladder

Largest  measuring 7mm.

2)E/o 22*17mm exophytic cyst noted in upper pole of left kidney

Impression:

Cholelithiasis

Left renal cortical cyst

B/l raised echogenesity of kidneys 

CXR:

Treatment:

1.T.ONDANSETRON 4MG PO /OD

@8AM

2.T.PAN 40 MG PO /OD @8AM

3.T.PREGABALIN M 75MG PO /OD @2PM

4.T.BEPLEX FORTE PO /OD@8PM

5.SYP CREMAFFIN 10ML PO /HS