47 year old female presented with abdominal distentionand pedal edema

November 5 2022

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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.

CHIEF COMPLAINTS 

Presented with abdominal distension ,pedal edema and shortness of breath since 2 months.

HISTORY OF PRESENTING ILLNESS

patient was apparently asympotomatic 2 months back then she developed pedal edema bilaterally which was insidious onset gradually progressive to current state it is pitting type extending from foot to hip 

abdominal distension since 2 months which is diffuse,nontendor for which she went to local hospital and was diagnosed as a case of diabetic nephropathy ,Hypertension,Hypothyroidism and she was put on conservative management but her abdominal distension didnot revert back so she came to our hospital.

PAST HISTORY

History of Diabetes since 6 years , 

History of hypertension since 2 years

History of hypothyroidism since 2 years.

No history of asthma, epilepsy and past surgical history.

FAMILY HISTORY 

No significant family history

PERSONAL HISTORY

Diet:mixed 

Appetite: decreased 

Bowel and bladder: regular 

Sleep: adequate 

Addictions: absent

DAILY ROUTINE

She is a housewife and she wakes up at 5AM freshen up ,prepares breakfast and eats breakfast at 9AM after having breakfast she does her household chores like washing clothes,cleaning,watching television,and takes nap after meal for 2 hours daily and prepare dinner,eat and sleep at 9pm.

GENERAL EXAMINATION

Patient is conscious, coherent, coperative.       Moderately built and nourished.

Pallor: present.

Icterus: absent 

Clubbing: absent 

Cyanosis: absent 

Lymphadenopathy: cervical lymphadenopathy present. 

Edema : bilateral edema is present from toes to hip. 

VITALS: 

BP: 150/90 mmHg

Pulse rate: 90 beats per min.

Respiratory rate : 16 cycles per min 

GRBS:290mg/dl

Temperature: afebrile.

SYSTEMIC EXAMINATION

CARDIO VASCULAR SYSTEM

S1,S2 heard , no murmers.

RESPIRATORY SYSTEM: bilateral air entry present, normal vesicular breath sounds.

PER ABDOMEN

Inspection: distention.

Palpation: soft , non tender, no organomegaly.

CNS EXAMINATION

HIGHER MENTAL FUNCTIONS:

Conscious, coherent, cooperative

Appearence and behaviour:

Emotionally stable

Recent,immediate, remote memory intact

Speech: comprehension normal, fluency normal.

CRANIAL NERVE:

All cranial nerves functions intact

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,presure- intact in all limbs

Posterior column:

Fine touch, vibration and proprioception are intact.

Motor system : intact.

INVESTIGATION

Cytology report.

PROVISIONAL DIAGNOSIS

Diabetic nephropathy with ascites .