A 45YR OLD FEMALE WITH PEDAL EDEMA AND SOB

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 CASE BLOG 

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  • I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 
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CASE HISTORY:

A 45 yr old Female patient hostel cook came with complaints of lower limb swelling, facial puffiness shortness of breath since 1yr and decreased urine output since 15 days
when we investigated her present history patient said that she is apparently asymptomatic 1yr ago then she developed lower limb swelling and facial puffiness since 1yr- onset was insidious and progressive aggravates on activity and relieves on rest
Shortness of breath since 1yr Grade 2 according new york heart association(NYHA) onset is insidious but not progressive
Decreased urine output since since 15 days onset insidious progressive
No h/o of pus in urine and also blood in urine
No h/o fever nausea vomiting
No h/o palpitations
No h/o chest pain 
she also has history of hypertension since 1yr  incidentally and when asked her personal history she said she on mixed diet, appetite and sleep were adequate, bowel and bladder normal and no addictions 

 EXAMINATION:

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative, well oriented to time, place, person
she has pallor and pedal edema but no icterus, cyanosis, clubbing and lymphadenopathy

VITAL SIGNS:

TEMPERATURE: Afebrile
BLOOD PRESSURE:130/80mm Hg
RESPIRATORY RATE: 24cycles/min
PULSE RATE:84 Beats/min
sPo2:98%

SYSTEMIC EXAMINATION:

PER ABDOMEN EXAMINATION:

Flat shaped abdomen and umbilicus is slightly retracted and inverted and gentle rise and fall of abdomen during inspiration and expiration, no visible pulsations,no visible peristalsis, no striae and no prominent superficial veins
no tenderness, palpable masses, hernial orifices, free fluid
liver, spleen, kidney not palpable
On percussion no shifting dullness
On auscultation normal bowel sounds
No bruit 

Here are the clinical images:


CARDIO VASCULAR SYSTEM:

Jvp is 5cm of H20
No visible pulsations and chest wall defects
on palpation normal apical impulse at left 5th ICS 1cm medial to midclavicular line
and no parasternal heaves and impulses and no thrills
on auscultation normal s1 and s2 heard and abnormal and pathological sounds

RESPIRATORY SYSTEM:

Normal b/l symmetrical movement of chest and trachea is central on inspection
on palpation we normal chest expansion no tenderness over chest wall, normal vocal fremitus
on percussion resonant note heard in all lung fields and on auscultation bronchial sounds in tracheal region and vesicular in lung fields

CENTRAL NERVOUS SYSTEM:

Higher mental status is normal and no focal neurological deficits elicited 

INVESTIGATIONS:

Complete hemogram, complete urine examination, random blood sugar, renal function tests, ultra sound

abnormal findings:

  1. on ultrasound we found bilateral grade-3 RPD
  2. creatinine raised to 14.2mg/dl (normal:0.6-1.1)
  3. abnormal urea and uric acid levels
  4. she is anemic (HB:7.9GM/DL)


DIAGNOSIS:

CHRONIC KIDNEY DISEASE?


 

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