A 50 year old female patient with loin pain and pedal edema

This is an online e-log book to discuss our patients de-identified health data shared after taking his/her/guardian's 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 blog also reflects 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 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.

CHEIF COMPLAINT:
A 50 year old female patient who is resident of athmakur mandal suryapet district and home maker came to the casuality with cheif complaint of loin pain since 1 year and pedal edema since 1 month.
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 1 year back then she developed pain in the loin region since 1 year, which was gradually progressive,non radiating, has no relieving and aggravating factors. Then she developed bilateral pedal edema which is pitting type since 1 month 
No history of fever

HISTORY OF PAST ILLNESS:
N/k/c/o diabetes, Asthma, epilepsy ,hypertension ,CAD.
Usage of NSAIDS more than 2 years.denovo hypertension due to usage of NSAIDS more than 2 years.

PERSONAL HISTORY:
Married
Appetite lost
Sleep is inadequate
Diet mixed
Bowel movements regular 
Bladder movements normal 
No known allergy
FAMILY HISTORY: No known relevant family history.
GENERAL EXAMINATION:
Patient is conscious, coherent , co-iperative and well oriented to place person and time.
Physical examination:
Pallor : present
Icterus :no
Cyanosis :no
Clubbing of fingers: no
Lymphadenopathy: no
Malnutrition :no
Dehydration: no
Temperature :98 F
Pulse rate: 92 beats per minute 
Respiratory rate :16 cpm
Blood pressure: 160/100mmhg

SYSTEMIC EXAMINATION:
Cardiovascular system:
Inspection: elliptical and bilateral symmetrical chest,
No visible engorged veins, scars and sinuses on the chest 
Palpation:
Thrills no
Cardiac murmurs no
Cardiac sounds s1 s2 heard.
Apex beat palpable at 5 th intercostal space medial to mid clavicular line .
Respiratory system:
Inspection: bilateral symmetrical,
Trachea is  central, 
No scars , sinuses or visible pulsations,
Suprasternal and supra clavicular notching is present.
Palpation  : all inspectory findings are confirmed.
No local raise of temperature.
No tenderness.
Dysponea :no
Wheezing: no
Ascultation:Breath sounds vesicular
Abdominal examination:
Shape of abdomen obese 
Umbilicus : central and inverted No scars are visible.
Tenderness :no
Palpable masses: no 
Free fluid: no ,no organomegaly.
No sinuses
Palpation:
Liver not palpable
Spleen not palpable
Bowel movements regular
Central nervous system:
AaPatient is conscious and speech is normal.
No neck stiffness
No meningial signs,
Sensory system normal,
Motor system normal .
PROVISIONAL DIAGNOSIS:
Chronic kidney failure 
Anaemia

INVESTIGATIONS:


2D echo:

TREATMENT:
Inj furosemide
Tab Sodium carbonate (nodosis)
Tab NICARDIA
Tab shelcal
Cap bion
Inj erythropoietin
Inj iron sucrose
Dialysis 

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