74 yr old female with Shortness of breath and Generalized edema

July 18, 2022

74 yr old female with Shortness of breath and Generalized 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.

74 yr old female patient admitted with chief complaints:

1. Shortness of breath since 10days

2. Generalized edema since 3-4 months

HOPI:-

Patient was apparently asymptomatic 2 months back then she developed shortness of breath (grade 4) on 30th may and was admitted to Govt. hospital where she stayed for 2days and was relieved after medication.

On 1st june she consulted orthopaedic for knee and back pain and was diagnosed as arthritis and kidney failure(60 percentage are damaged).

After knowing about her kidneys failure she developed anxiety and fear and started behaving like little child (shouting, hitting herself) which lasted for 10 days and was normal for next 10 days.

In the mid june she again developed shortness of breath (grade 4) and was admitted in various private hospital and govt.hospitals and at last was admitted in our hospital yesterday.

7days back she developed seizures (lasted for 10 mins) since then she started yelling.

History of filariasis 40yrs back.

History of knee pains and bloating since 30yrs and intake of medications.

3-4months back she started developing generalized edema.

Daily routine:

She wakes up at 6am and takes chai at 7am and does normal daily chores

Takes breakfast at 8:30 am( portridge ,jowar ,bajra) and does daily chores and walks for sometime.

She takes her lunch at 1 pm (rice +curry+curd) and then chats with neighbours.She takes chai at 4:30 pm does the Remaining daily chores and takes her dinner ( rice+curry+curd) at 9 pm and goes to sleep.

Past history:

K/c/o DM, HTN Since 1 month

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

Personal history

Diet:Mixed

Appetite:Normal

Sleep: inadequate

Bowel and bladder movements:Regular

No Addictions

Family history: No significant family history

GENERAL EXAMINATION:

Patient is conscious, non cooperative, coherent and Irritable.