42 yr old female patient with Chief complaints of Shortness of breath, vomting and pedal edema

July 01, 2022

42 yr old female patient with Chief complaints of Shortness of breath, vomting and 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.

A 42 yr old female admitted with CHIEF COMPLAINTS of Vomiting, Shortness of breath and bilateral pedal edema.

{ } HOPI :-

SEQUENCE OF EVENTS-

Patient was apparantly asymptomatic 3yrs back.Then she developed dizziness and diagnosed as hypertension for which she had treated by private practitioner and was on medication(Nicardia) for 1 month and stopped them.

Then after a year she developed ethmoidal polyps for which she had undergone surgery and since then she was suffering from cold and sneezing for which she took tablets.

In the same year she suffered from overbleeding and stomach pain for which she took medication.
After 6 months she started having shortness of breath, vomiting, pedal edema and decreased urine output for which she was admitted to the hospital and was daignosed as kidney failure .Since then she was on dialysis (weekly twice).

4-5 months back she started developing ascites.

She was shifted to icu for shortness of breath ,fever and chills on 30/6/22.

Past history:
k/c/o- HTN since 3 yrs
Not a k/c/o DM,Asthma,TB,Thyroid, Epilepsy

Personal history:
(Menstrual history):
Age at menarche- 13yrs
Regular cycles , 2-3 pads per day with full soakage.
Normal menses.

Diet- Mixed
Appetite: Decreased
Sleep- disturbed
Bowel and bladder movement-irregular
No addictions

Family history:- No significant family history

GENERAL EXAMINATION

patient is conscious, coherent and coperative

Well oriented to time, place and person

Decreased muscle mass in the upper limbs

Pallor- present

No icterus, cyanosis, clubbing,lymphadenopathy
Bilateral pedal edema is present which is of pitting type