47 YEAR OLD FEMALE WITH PEDAL EDEMA AND SOB

Kausalya Varma, Intern 

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

 I’ve 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. 



47 YEAR OLD FEMALE WITH PEDAL EDEMA AND SOB 


CHIEF COMPLAINTS: 
A 47 year old female who is a homemaker by occupation, and a resident of Nalgonda came to the OPD with the chief complaints of pedal edema, shortness of breath since 15 days, cough since 13 days and fever since 3 days.

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 15 days back she developed pedal edema which was insidious in onset starting up to level of the ankles and gradually progressing up to knees, it is putting type. H/O similar complains on and off for the past 1.5 years 
Associated with SOB grade 2, not associated with orthopnea, PND 
SOB is insidious onset  a from last 12 days(grade 2 to grade  3 sob) and relived on rest for which she went to hospital and her hemoglobin levels found 3% and was advised for blood transfusion. Since the last 4 days sob has reduced to grade 2 
She developed cough since 12 days which productive in nature, yellowish white sputum no blood stain,non foul smelling
She has complaints of fever since 3 days that are not associated with chills and rigors
No c/o burning micturition, loose stools, vomitings, pain abdomen or rashes 
H/O irregular menses 1 year back and was admitted for menhorragia and was transfused PRBC 1 unit and was diagnosed with uterine fibroids 
No other bleeding manifestations 

PAST HISTORY 

She has had similar complaints of pedal edema for the past 1 year which is on/off 
Not a K/C/O DM, HTN, epilepsy, asthma, TB or CAD 

MENSTRUAL HISTORY  

She attained menarche at the age of 14
earlier she used to have regular 30 days Menstrual cycle with 3 days flow ,no clots

From 22march,2022 she is having regular 20 days cycle ,heavy Menstrual bleeding for 5 days for which she went to hospital and was diagnosed by fibroid uterus and was advised for hysterotomy because of her low hb level surgery was not done.she under went blood transfusion later her Hb was found to be 8gm% which was not adequate for surgery
Since  last 6 months spotting is seen for every 15 to 20 days of cycle



PERSONAL HISTORY 

Normal appatite 
Mixed diet
Adequate sleep
Regular Bowel and Bladder movement 
No addictions 
No allergies 
Daily routine-she wake up at 5 am does daily  work(sweeping,washing cloths)then she will have a glass of milk  at 12 pm she will have rice ,dal and curry then she will have sleep for a hour 
Watch TV for 1 to 2 hr then at 9pm she will have dinner(chapati and curry)
Sleep at 10 pm

Dietary history 
1 glass milk-129 cal,8g
Lunch-rice 2 cups-414 cal,6.6g
            Curry 1 cup -80cal,6g
             Dal 1 cup -89cal,7g
Milk 1 glass -129 cal,6.6 g
Dinner-chapatti2 and half-172 cal,8g
             Curry-80 cal,6
Total -59.6 g and 1091 cal
She is deficit of 1509 cal


GENERAL EXAMINATION 

Pt is C/C/C
BP:140/80mm hg
PR:96bpm
RR:20/min
Temp : Afebrile 
Patient was consious, coherrent and co-operative. Well oriented with time place and person. Well built and nourished 
Pallor 
B/L pedal edema
No icterus 
No clubbing
No cynosis
No generalized lymphadenopathy 

Systamic examination 
Cvs- 


Jvp raised
Apex 6th ICS, 1cm lateral to MCL 
Palpable P2+
ESM +
Mitral, tricuspid, atrial, pulmonary areas- murmurs increased on bending forward
No axillary, carotid radiation 
Parasternal heave
S1 and s2 heard No murmurs 



Rs-  Trachea central
Normal vesicular breath sounds heard 
Left ISA, ICA, right ISA crepts 

Per abdomen-

INSPECTION: abdomen :round 
Moves with respiration
No abdominal distension 
Umblicus is central and inverted 
No engorged veins
No scars and no sinsus are seen
Hernias orifices are clear.

PALPATION:
All inspectory findings are confirmed 
No tenderness in the abdomen

 PERCUSSION:No significant fingings

AUSCULTATION: Bowel sounds heard 
No bruits.


Cns-no focal neurological deficit 



CLINICAL IMAGES











INVESTIGATIONS 










Current lab reports (08/01/23)








Repeat 2D echo 




Repeat chest X-ray (8/01/23) 


Bacterial C/S report 


Repeat ECG (8/01/23)



Updated fever charting 



C/S REPORT 





PROVISIONAL DIAGNOSIS 
Heart failure with preserved ejection fraction 
?Dimorphic anemia
?CAD 

TREATMENT

02/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD

3/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD

1 unit PRBC infusion on 3/1/23

4/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD

5/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD
Syp Potklor 15ml in 1 glass of water PO BD 

1unit PRBC infusion on 5/1/23

6/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD
Syp Potklor 15ml in 1 glass of water PO BD 
Tab aldactone 50mg PO OD 

7/01/23

Fluid restriction <1.5lt/day
Inj LASIX 40mg IV TID 
Neb Ipraven and Budecort 8th hourly 
Tab ecosporin AV PO HS
Tab Carvedilol 3.125 mg PO BD 
Inj Vitcofol 1500mg IM OD he patient was apparently asymptomatic
Inj HAI SC TID 
Inj Ceftriaxone 1g IV BD 
Tab orofer XT PO OD
Syp Potklor 15ml in 1 glass of water PO BD 
Tab aldactone 50mg PO OD 

8/01/23

Fluid restriction <1.5lt/day 
Inj Ceftriaxone 1g IV BD
Inj Vitcofol 1500mg IM OD 
Tab Metformin 500mg PO OD 
Tab ecosporin AV PO HS 
Tab LASIX 20mg PO BD 
Tab Carvedilol 3.125mg PO BD 
Tab Orofer XT PO OD 
GRBS 7 point profile monitoring 
Syp Ascoryl LS 10ml PO TID 
Tab LASIX 20mg PO BD 

9/01/23

Fluid restriction <1.5lt/day 
Tab Metformin 500mg PO OD 
Tab ecosporin AV PO HS 
Tab LASIX 20mg PO BD 
Tab Carvedilol 3.125mg PO BD 
Tab Orofer XT PO OD 
GRBS 7 point profile monitoring 
Tab LASIX 20mg PO BD 




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