60 year old lady came to opd with chief complaints of bilateral pedal edema

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.

This E blog also reflect my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan

CASE:

A 60 year old lady , who was an agricultural labourer by occupation (but has stopped working since 4 years bcz of pain in both knees), came to the hospital with complaints of  pain in both knees since 4-5 years, facial swelling since 2-3 months, pedal edema since 1 week.

HOPI:

The patient was apparently asymptomatic 4-5 years ago. She then started developing pain in both her knees which is aggravated on walking and standing, relieved on resting and medications (painkillers). She stopped working due to the pains.

2-3 months ago, she developed facial puffiness which was insidious in onset and gradually progressive in nature. It appears maximally in the mornings and gets relieved by the end of the day. 

1 month ago, she had a tooth extraction on the left side and still has facial puffiness on the left side.

1 week ago, she had pedal edema upto her ankles which was pitting in nature which appears maximally in the morning and subsides by the end of the day for which she went to Nalgonda Govt. hospital where she undergone all investigations and doctor prescribed her with some medication {potassium citrate and magnesium citrate syrup ,metoprolol 50mg , Rosuvastatin 10 mg , Furosemide 40 mg , Aspirin 75 mg }. Her edema gradually subsided by itself after a week.

She came to the hospital now to find a working solution for her joint pains and to find out about why her pedal edema appeared and disappeared.

DAILY ROUTINE:

The patient wakes up in the morning at 5:30 and begins household chores, eats breakfast at 8:00. She smokes tobacco at this time.

She then passes her time by talking with family members or neighbours till 11:00, when she cooks her lunch and eats lunch late, around 3:00-4:00pm

She has tea occasionally in between, when she visits family. She spends time sleeping or talking with friends and family in person or on the phone.

At night she take roti , She may or may not smoke tobacco again. She then sleeps at around 10:00pm.

This has been her routine since 4 years, after she stopped working.

PAST HISTORY: 

N/K/C/O of DM,HTN,TB,Asthma,epilepsy,CVD,CAD

FAMILY HISTORY:

Not significant 

TREATMENT HISTORY:

Patient has a history of using NSAIDS 3-4 days a week since 4 years for the joint pains which was suggested by RMP

SURGICAL HISTORY:

Tubectomy 30 years back 

Cataract surgery in left eye 6 months ago

PERSONAL HISTORY:

Appetite: normal

Diet: mixed

Sleep: adequate

Bowel movements: regular 

Micturition: normal 

No known allergies

ADDICTIONS:

Smokes tobacco 5-6 times per day since …..

Alcohol occasionally started ….

MENSTRUAL HISTORY:

Attained menarche at 20 years of age 

OBSTETRIC HISTORY:

Age at marriage: 18 years

Age at first child:20

Obstetric formula:G5P5L5

All were normal vaginal deliveries 

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative and well oriented to time, place and person

The patient is well built and well nourished 

No pallor, icterus, cyanosis , clubbing ,koilonychia , lymphadenopathy 

Pedal edema present 


VITALS:

Temperature- Afebrile 

Blood pressure- 120/80

Pulse rate - 82 bpm

RR - 18 cpm

SYSTEMIC EXAMINATION:

CNS :Patient is conscious ,coherent ,cooperative and well oriented to time ,place and person

CVS:S1,S2 heard , no added sounds , apex beat was ausculted at medial to midclavicular in 5th intercoastal space , no raised JVP

RESPIRATORY SYSTEM:Trachea central , normal vesicular breath sounds heard , no added sounds

ABDOMEN: Distended, no palpable organs

INVESTIGATIONS :








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