60 y old female with anasarca and vomitings
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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 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
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
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