47year old female with pedal edema and abdominal distension

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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. 

          B.Gayathri  Roll no :22

                         CASE

 This is a case of 47yr old female patient resident of narketpally presented with 

                                                                                 CHIEF COMPLAINTS:

               pedal edema since 2 months abdominal distension since 2 months shortness of breath since 2 months 

HISTORY OF PRESENTING ILLNESS

   SEQUENCE OF EVENTS:                                               patient was apparently asympotomatic 2 months back then she developed pedal edema bilaterally which was insidious onset gradually progressive to current state it is pitting type extending from foot to hip 

         abdominal distension since 2 months which is diffuse,nontendor for which she went to local hospital and was diagnosed as a case of biabetic nephropathy ,Hypertension,Hypothyroidism and she was put on conservative management but her abdominal distension didnot revert back so she came to our hospital   

 DAILY ROUTINE:

             she is a housewife and she wakes up at 5AM household chores and eats breakfast at 9AM after having breakfast she does her household chores like washing clothes,cleaning,watching telivision,an takes nap after meal for 2 hours daily and prepare dinner,eat and sleep at 9pm. 

    PAST HISTORY:

           known case of diabetes since 6years.  knowm case of Hypertension since 2months Known case of hypothyroidism since 2 months

     Not a known case of epilepsy,asthma

Cervical lymphadenopathy FNAC gave positive for tuberculosis for which she is under treatment .

  PERSONAL HISTORY

            Diet:mixed 

           Appetite:decrease 

         Bowel is regular,bladder- decreased urine output

          sleep:adequate 

         No addictions 

     FAMILY HISTORY:

         Not significant

   TREATMENT HISTORY:

   GENERAL EXAMINATION: 

         patient was                consious,coherent,cooperative.

      Moderatly built and nourished.

     well oriented to time,place and person 

   PALLOR: present

  ICTERUS: absent 

 CLUBBING: absent

 CYANOSIS:absent 

 LYMPHADENOPATHY:absent

only cervical lymphnodes swelling is present bilaterally. 

    EDEMA:: bilateral edema is present from toes to hip. 

     VITALS

      BP- 120/80mmhg

      PR- 72b/min

       RR- 16b/min

  SYSTEMIC EXAMINATION:

    - CVS:S1 and S2 heard.no murmurs 

RESPIRATORY- bilateral air entry present ABDOMEN:soft and non-tendor 

 CNS:All cranial nerves functions intact

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,presure- intact in all limbs

Posterior column:

Fine touch, vibration and proprioception are intact

MOTOR SYSTEM : 

                      Right          Left

Bulk: 

Inspection.      N.              N

Palpation.        N.             N

Tone: 

UL.                  N.               N

LL.                    N.             N

REFLEXES

 

         B      T      S      K        A         P

 

R      2+     -     -       -          -         Flexor

 

L       2+     -     -       -          -         Flexor

CEREBELLUM:

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

 Diabetic nephropathy causing nephrotic syndrome leading to ascitis

 TREATMENT: