70 YEAR OLD FEMALE WITH PEDAL EDEMA

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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. 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 patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINTS

• A 70 year old Female Patient came to OPD, for her regular check up
• She was admitted on the basis of deranged Renal Function Tests

 

HISTORY OF PRESENT ILLNESS

 

• The patient was apparently asymptomatic 2 years back, when she developed COVID -19, and went to a hospital where she was diagnosed with CKD, based on her raised Urea and Creatine. 

• On further questioning she reported to have had a Fracture of her Left Hand 4 years ago, for which she was prescribed NSAIDS, and was taking them on and off since then.

• She also developed Pedal Edema 1 year back which was pitting type.

• Decreased Urine output since 1 year.
  

• There is no history of fever, SOB, palpitations, Chest pain, cough or burning micturation

 TIMELINE OF EVENTS:

2019 - Fracture of Left Hand, Started NSAIDS

2021 - Infected with COVID -19, got diagnosed with CKD

2022 - Developed Pedal Edema, Decreased Urine Output

4.01.2023 - Admitted for Hemodialysis 

PAST HISTORY

•  The patient is a known Hypertensive since 2 years.
  
• The patient is not a known case of DM, Asthma, TB, Epilepsy'

FAMILY HISTORY

• No relevant family history. 

PERSONAL HISTORY

• Diet - Mixed
• Appetite - Normal
• Bowel and Bladder - Regular
• Sleep - Adequate
• Addictions -  None

TREATMENT HISTORY

• Patient is on medication for Hypertension. 
  

 

GENERAL EXAMINATION

The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 

Moderately built and well nourished

Presence of pallor 

Edema of Lower Limbs is present

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy,

CLINICAL IMAGES

 

VITALS:

Temp: Afebrile
PR: 126 bpm
BP: 130/90 mm Hg
RR: 38 cpm
SPO2: 98% @ RA

SYSTEMIC EXAMINATION:

Patient is examined in a well lit room and in a sitting position.

RS: BAE +, NVBS

CVS: 

S1 S2 +
No murmurs heard

Apex beat - not assessed

PER ABDOMEN:

INSPECTION:  Shape of Abdomen -  Normal, No sinuses, fistulas. Umbillicus -  Central, not everted

PALPATION: Inspectory Findings Confirmed 

Soft, non tender
No Organomegaly

PERCUSSION : Tympanic

AUSCULTATION:  Bowel sounds Heard

CNS: 

 No focal neurological deficits 

Cranial Nerves intact.

PROVISIONAL DIAGNOSIS:

CHRONIC RENAL FAILURE  - Secondary to NSAID abuse

INVESTIGATIONS

19-7-21

28-9-21

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

4-1-23

USG - 4-1-23

4-1-23

MANAGEMENT

•  Tab. LASIX
• Tab. MINIPRESS
• Tab. NODOSIS
• Tab. SHELCAL
• Tab. OROFER
• Inj. EPO
• HEMODIALYSIS          
  

 

 

PROVISIONAL DIAGNOSIS

CKD 2° TO NSAID ABUSE

ANEMIA 2° CKD 

AKI ON CKD