A 50 year old female patient with loin pain and pedal edema

A 50 year old female patient with loin pain and pedal edema

January 17, 2023

This is an online e-log book to discuss our patients de-identified health data shared after taking his/her/guardian's 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 patients clinical problems with collective current best evidence based inputs.

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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.

CHEIF COMPLAINT:

A 50 year old female patient who is resident of athmakur mandal suryapet district and home maker came to the casuality with cheif complaint of lower back pain since 1 year and pedal edema since 1 month.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 1 year back the she developed pain in the loin region since 1 year. Then she developed facial puffiness and bilateral pedal edema which is pitting type 1 month ago

Loss of appetite

Sleep is inadequate due to pain

No history of fever

HISTORY OF PAST ILLNESS:

No known complaint of diabetes, Asthma, epilepsy _hypertension since 1year

PERSONAL HISTORY:

Married

Appetite lost

Bowel movements regular

Micturation normal

No known allergy

FAMILY HISTORY: No known relevant family history.

GENERAL EXAMINATION:

Patient is conscious, coherent , co-operative and well oriented to place person and time.

Physical examination:

Pallor present

Icterus no

Cyanosis no

Clubbing of fingers no

Lymphadenopathy no

Oedema of feet no

Malnutrition no

Dehydration no

Temperature 98 c

Pulse rate: 92 beats per minute

Respiratory rate 16 cpm

Blood pressure 160/100mmhg

SYSTEMIC EXAMINATION:

Cardiovascular system:

Inspection: elliptical and bilateral symmetrical chest,

No visible scars and sinuses on the chest

Palpation:

Thrills no

Cardiac murmurs no

Cardiac sounds s1 s2 present

Apex beat palpable at 5 th intercostal space medial to mid clavicular line .

Respiratory system:

Inspection: bilateral symmetrical,

Trachea is placed central,

No scars , sinuses

Palpation s : all inspectory findings are confirmed.

No tenderness.

Dysponea :no

Wheezing: no

Ascultation:Breath sounds vesicular

Abdominal examination:

Shape of abdomen obese

Umbilicus : central and inverted No scars are visible.

Tenderness :no

Palpable masses: no

Free fluid: no

Central nervous system:

Patient is conscious and speech is normal.

Sensory system normal,

Motor system normal .

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Chronic kidney disease