43 year old female with Pedal Edema, Generalised Weakness.
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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.
43 year old female resident of Narketpally came to OPD with chief complaints of
Swelling in bilateral lower limbs upto ankle since 15 days
Generalised weakness since 1 week
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 days ago. She noticed swelling in her both lower limbs until ankle , insidious in onset , gradually progressive in nature , Pitting type . No aggravating and relieving factors.
H/o generalised weakness since 1 week.
Increased menstrual bleeding since 3 months but duration remained same not associated with clots .
No h/o orthopnea and paroxysmal nocturnal dyspnea.
No h/o decreased urine output, burning micturition .
No H/o nocturia, polyuria
No H/o nausea, vomiting, loose stools, constipation.
No H/o fever, cough ,cold .
No H/o palpitations, sweating .
No H/O chest pain.
No H/o abdominal distension, abdominal pain.
No H/o hematuria.
No h/o headache,sleep disturbances.
PAST HISTORY:
4 years ago , patient had complaints of generalised weakness and visited her local doctor , blood investigations were done and her Hemoglobin was around 6 gm/dl .
So she took iron and folic acid supplements for a month and stopped.
On 19 Jan 2024 , patient came with similar complaints to our OPD , investigations like complete blood picture,serum electrolytes , creatinine and blood urea were done and was advised to get admitted .
Not a k/c/o Diabetes Mellitus, Hypertension, Tuberculosis,CAD, Thyroid disorders.
MENSTRUAL HISTORY:
Menarche - 13 years
28/5 - regular periods
Earlier 2- 3 pads / day
Not associated with clots .
Since 3 months increased bleeding during periods , duration remained same
Pads / day - 4 pads / day ( wholly filled)
PERSONAL HISTORY:
Diet - mixed
Sleep - Adequate
Appetite - normal
Bowel and bladder - regular
No addictions
No allergies
FAMILY HISTORY:
No significant history
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
She is moderately built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
No lymphadenopathy
On examination,edema is present below knee level
Vitals :
Temperature - 96.8 ° F
Blood Pressure -110/70 mmHg
Pulse Rate -89 bpm
Respiratory Rate - 16 cpm
SYSTEMIC EXAMINATION:
Per abdomen:-
On inspection
Shape of abdomen : flat
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver is not palpable
Spleen is not palpable
On percussion
Resonance note heard
On auscultation
Bowel sounds heard
CVS Examination:
Inspection
No raised JVP
Trachea appears to be central
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Palpation-
Trachea Central in position
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
Auscultation-
S1 and S2 heard, no murmurs heard
Respiratory Examination:
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
CNS Examination:
Conscious
Normal speech.
No neurological deficit found.
PROVISIONAL DIAGNOSIS:
Anemia under evaluation
Nutritional? Menstrual blood loss?
INVESTIGATIONS:
On 19 Jan 2024 .
Complete Blood picture:-
USG report
Positive findings - borderline splenomegaly
Right renal calculi
ECG
Heart rate -100 bpm ( tachycardia)
Normal sinus rhythm
Normal axis
On 23 Jan 2024
Hb- 5gm/dl
TLC - 5800
MCV - 61.7
MCHC - 23.1
MCH - 14.3
Platelet - 3.0
Serum iron - 31 micro gram / dl
Blood urea - 22 mg/dl
Serum creatinine - 0.6 mg/ dl
Blood grouping - B +ve
Serum ferritin -
Liver function tests :
Chest x-ray
On 24 Jan 2024
Fasting Blood sugar -285 mg/dl
FINAL DIAGNOSIS:
Severe Anemia Nutritional? Menorrhagia?
Denovo Diabetes mellitus
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