63YR OLD FEMALE WITH B/L 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.
Name : Supriya .K ( Intern )
Roll Number : 63
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.
Pitting type of edema ( Grade 2)
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 4 years ago (she had 3 lesions on scalp) used medication.
PERSONAL HISTORY :
Diet- mixed
Appetite-normal
Sleep- adequate
Bowel movements-regular
No addictions
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 - 210/120mm of Hg
Pulse rate - 88bpm
Respiratory rate -18 cpm
SYSTEMIC 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.
RS :
Bilateral air entry present
Normal vesicular breath sounds are heard
PER ABDOMEN
soft,non tender,no organomegaly
CNS
No focal neurological deficit
INVESTIGATIONS:
Chest Xray PA view :
BP CHARTING :
2D ECHO :
Concentric LVH (1.40cms )
No RWMA
Trivial TR+/AR+ ,No MR
Sclerotic thickened AV , No AS/MS
EF : 64 % RVSP : 38mmHg
Good LV systolic function
Diastolic dysfunction (+) ; No PAH /PE
IVC size ( 0.6 cms) - Collapsing
USG ABDOMEN:
PROVISIONAL DIAGNOSIS:
? HYPERTENSIVE URGENCY
? Hypertensive Crisis
? Severe Uncontrolled Hypertension
( K/C/O hypertension and DM2 since 10 years )
MANAGEMENT:
At 4PM 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
Treatment according to her BP values
SOAP Notes:
ICU
Day -2
Bed-6
S
Stools not yet passed
No Fever spikes
No head ache
O
Pt is Conscious, coherent, cooperative
Temp: 98.6 F
BP: 160 /100 mmHg
PR : 95bpm
RR : 14cpm
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and non tender
A
HYPERTENSIVE URGENCY
? Hypertensive Crisis
? severe uncontrolled hypertension
(k/c/o hypertension and DM 2 since 10 years
h/o psoriasis since 6years )
P
1) inj . labetalol 20 mg IV /SOS
if SBP > 160 mmHg
2) T. Telma H PO/OD
3) T. Cinod 10mg PO/BD
4) Hourly BP monitoring
5) T. Metformin 500mg PO/OD
6) vitals monitoring 4th hourly
ICU
bed-6.
Day 3
S
stool passed
No fever spikes
O :
Pt is c/c/c
Afebrile
PR 96 bpm
BP 150/90
CVS: s1 s2 +
RS: BAE + , NVBS
P/A: obese , soft , NT
CNS: NFND
Grbs: 210 mg/ dl @8 am
A:
HYPERTENSIVE URGENCY WITH UNCONTROLLED HYPERTENSION
P:
1.inj.labetolol 20 mg IV/ sos of SBP >160 mmHg
2.T.Telma-H PO/OD
3.T.cinod 10 mg PO/BD
4.T.Metformin 500 mg PO/BD
5.T.Met-XL 50 mg Po/OD
6.T.Minipress XL 2.5 mg Po/OD
7.2 Hourly Bp monitoring
8.vitals Monitoring 4 th hourly
AMC
Day -4
Bed -2
unit -3
S
Stool passed and no fever spikes
O
Pt is conscious ,coherent , cooperative
Temp: afebrile
BP: 120/80mmHg
PR : 88bpm
RR :18 cpm
GRBS 194 mg/dl
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and nontender
A
HYPERTENSIVE URGENCY ,
?HYPER TENSIVE CRISIS
? METABOLICSYNDROME
? SEVERE UNCONTROLLED HYPERTENSION
?PVD
H/O PSORIASIS SINCE 6 YEARS
K/C/O.HYPER TENSION AND DM 2 SINCE 10 YEARS
P
tab metformin 500 mg po/bd
tab cinod 10 mg po/ bd
tab met xl 50 mg po/ od
tab minipress xl 2.5 mg po/od hs
bp monitoring 2 hrly
vitals and grbs 6 hrly
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