60 y old female with anasarca and vomitings

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Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Abhignya.    Roll. No 71

On 28.02.22

Patient presented with complaints of 

-Bilateral pedal edema 

-vomitings 

Patient was apparently asymptomatic 6months back then she noticed pedal edema till ankel which was pitting type.  It was on and off . 

But since 1 month this pitting edema was not relieving and it extended upto inguinal region.

Edema aggravated on walking and in the morning. 

*She also has mild  abdominal distension and     edema of face and hands. 

Pedal edema is associated with itching  and dragging type of pain 

*Pt. also complains of vomitings since 1 month. 

Vomitings are non projectile and the after the food intake and contents were food particles

*patient complains of decreased appetite and decreased food intake since 2 months 

*Intermittent pricking type of abdominal pain

Since 2 days 

 

No history of decreased Urine output, burning micturation and increased frequency of micturation. 

No history of palpitations, shortness of breath, lethargy.

Peripheral sensations present. 

 Patient went to a other hospital 1 week back, there she was given medications. She used them for 3 days after which edema over face and upper limb subsided , vomitings and abdominal pain also subsided. But her edema of lower limbs and abdominal distension didnot subside.  So the patient presented to our hospital. 

Past history :

 She is a known case of Type 2 Diabetes mellitus since 10 yrs and she was using Insulin since then but she stopped talking insulin since 1 month as she was feeling hypoglycemic after taking it. 

Not a known case of Hypertension , CAD, TB, epilepsy. 

Personal history :

Decreased appetite 

Mixed diet

Bowel and bladder habits are regular 

Sleep is adequate 

No addictions

No food and drug allergies 

General examination 

Patient is conscious, coherent,co operative.

Thin built and poorly nourished

pallor present 

No Icterus , cyanosis , clubbing, lymphedenopathy

bilateral pitting edema of lower limbs till upper part to thigh

VITALS

Afebrile

BP: 140/90mmhg

PR- 87bpm

RESP. RATE: 17CPM

Spo2: 97% room air

GRBS : 153mg/dl

CVS examination : S1 S2 heard no murmurs 

Respiratory system : 

 Bilateral air entry present 

 Normal vesicular breath sounds heard 

CNS : Higher mental functions normal

ECG:

Hemogram:

CUE

 

Ultrasound abdomen :

Renal function test

Treatment 

Fluid restriction -less than 1.5 lit per day

Salt restriction - less than 2 g per day

Tab. Lasix 40mg BD

Tab. Orofer xt OD

Tab. Nodosis 500mg BD

Inj. Erythropoietin 4000 IU s.c weekly 

GRBS monitoring ...Inj Human Actrapid if required. 

Hemodialysis

Diagnosis : Diabetic nephropathy with anaemia