Case: 35 year old woman with scleroderma, pedal edema and ascites
Neha Pradeep, MBBS 9th semester
Provisional Diagnosis:
Roll no: 99
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.
Case:
55 year old female patient, who is an ASHA worker, came with the complaints of swelling of both legs since 6 days, and abdominal distension since 6 days.
History of Presenting Illness:
Swelling in both legs bilaterally, which was insidious in onset and progressive. It has worsened in the last 3 days. It is of pitting type.
Abdominal distension since 6 days, which has worsened since the last 2 days.
There has been a decreased urine output since two days.
There is a history of vomiting, 4-5 episodes daily since 1 day. The vomitus is non bilious and non projectile.
No history of loose stools.
History of Past Illness:
Patient was dengue positive last month and was treated symptomatically.
She is not a known case of diabetes, hypertension, of Tuberculosis.
No past surgical history.
Personal History:
Diet: mixed
Appetite: normal
Sleep: Adequate
Bowel and Bladder: Regular till 2 days ago.
No allergies
No addictions
On examination:
Patient is conscious, cooperative and coherent.
Moderately built and moderately nourished.
Pallor: Absent
Icterus: Absent
Clubbing: Absent
Cyanosis: Absent
Lymphadenopathy: Absent
Edema: Present, pitting type
Vitals:
Temp: 98.6°F
Skin:
Stretched, shiny skin is present on the face and over the shins.
Hypopigmented spots were seen bilaterally on the anterior aspect on the legs.
Systemic Examination:
CVS :S1S2 +
RS : BAE+, NVBS
CNS: No focal deficits
Lab Results:
Ascites under evaluation
Bilateral pleural effusion
Treatment:
1)Fluid restriction< 2L /day
2)Salt restriction <2g/day
3) Inj.zofer 4 mg IV.sos
4)Inj.Tramadol 1 amp in 100 ml NS/IV SoS
5)Tab.Dolo 650 mg po/sos
6)Syp.potchlor 10 ml po /BD in a glass of water
7)Abdominal girth monitoring
8)Daily weight monitoring
9)Vitals monitoring 6th hourly
10) Tab.Lasilactone 20/50 mg
11)Tab.ultracet 1 1/2-1/2-1/2-1/2(QID)
Comments
Post a Comment