A 63 year old female with bilateral pedal edema
December 15, 2022
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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.
CASE PRESENTATION
A 63 year old female resident of Nalgonda came to the general medicine OPD with the chief complaints of
•bilateral pedal edema since 10 days
HISTORY OF PRESENTING ILLNESS
patient was apparently asymptomatic 10days ago and then she developed bilateral pedal edema which is insidious in onset,gradually progressive, pitting type which is extending upto the knee(grade 2) associated with itching.
No aggravating and relieving factors.
History of nocturia (3-4times),snoring.
Not associated with abdominal distension, shortness of breath,cough,palpitations,chest pain,
No history of headache, blurring of vision.
vision.
PAST HISTORY
•she is known case of hypertension since 10 years (under medication Telma H)
•Diabetes mellitus since 10 years (under medication Metformin 500mg OD)
•History of humerus fracture 2 years ago which is treated conservatively (because of fall from steps)
•History of psoriasis 6 years ago (she had 3 lesions on scalp) used medication.
PERSONAL HISTORY
Diet- mixed
Appetite-normal
Sleep- adequate
Bowel movements-regular
No addictions
DAILY ROUTINE
she wakes up at 8 AM everyday and do her everyday rituals then she would have her breakfast at 10 AM.
She will not do regular household works(her maid will do).
She passes her day by running kiranam store.She takes her lunch at 1PM followed by short nap of 1hour,dinner at 8 PM and goes to sleep at 10 PM.
FAMILY HISTORY
her husband is also known case of hypertension and diabetes mellitus.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative well oriented to time, place and person. She is obese and moderately nourished.
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy.
VITALS
Temperature - 98.4°F
BP - 160/100mm of Hg
Pulse rate - 95bpm
Respiratory rate -14 cpm
GENERAL EXAMINATION
CVS
INSPECTION
Shape of chest- bilaterally symmetrical
Trachea - central
No visible pulsations
No scars,sinuses or dilated veins
PALPATION
No thrills,parastrenal heaves
AUSCULTATION
s1,s2 are heard
No murmurs
No raised jvp.
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular breath sounds are heard
PER ABDOMEN
soft,non tender,no organomegaly
CNS
No focal neurological deficit
INVESTIGATIONS
ECG
TREATMENT
At 11:35 AM in OP NICARDIA 20mg was given
After 30 minutes BP was recorded-170/130 mm of Hg
After sometime it was again 210/120mm of Hg.
After admitting in the ICU
LABETOLOL IV was given
DIAGNOSIS
Hypertensive urgency??
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