52 year female with fever and pedal edema( short case)
20 jan 20203 This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.
52 yrs female came to casualty with c/o sob since morning
C/o fever , cough pedal edema since 3 days
Hopi: pt was apparently asymptomatic 6 mnths back. She was complaing of low grade fever from 1 week burning micturation
Not associated with chills
No evening raise of temp
History of past illness: K / c /o HTN tab. Telma 40 mg AND DM from 20 yrs Is on tab. Glymi1
Herbal medication for PEDAL EDEMA stoped medication for no reason after one month development of pedal edema , fever and sob
Personal history: loss of appetite
Bowel and bladder movements notmal
Sleep adequate
No habits / addictions
she is married
Age of menarchy: 49
Local examination:
No pallor , icterus , cyanosis clubbing
Pedal edema present
Vitals: temp . 96.9f
PR: 78b/ min
RR: 24 c/ min
BP : 220/ 110 mmhg
Spo2: 98%
GRBS : 92mg%
Moderately nourished
Systemic examination:
Abdomin:
Inspection : distended abdomin
PALPATION:
no raise of temperature
no tenderness
Kidney and spleen not palpable
no palpable mass
PERCUSSION:
No fluid thrill
No Shifting dullness seen
AUSCULTATION:
bowel sounds heard
No bruit
RESPIRATORY:
INSPECTION:
Chest: symmetrical
Trachea: central
No drooping of shoulders,
no kyphoscoliosis
no use of accessory respiratory muscles
Movement with respiration is symmetrical on both sides
PALPATION:
trachea: central
no intercoastal widening
Vocal fremitus -normal
PERCUSSION:
No fluid thrill
No Shifting dullness seen
AUSCULTATION:
vesicular breath sounds
Crepts are heard
CVS:
S1&S2 heard
No thrills,no murmurs
CNS:
Concious
Speech:normal
No signs of neck stiffness
Sensory system :normal
Motor system: normal
Investigation
diagnosis: aki on ckd with HTN and DM
Differential diagnosis: pulmonary edema
Treatment: inj. Lasix 40 mg iv
Oxygen inhalation
T.nicardia 20 mg
Inj. Soda bicarbs
