A 60 YEAR OLD FEMALE WITH SOB AND PEDAL EDEMA

January 03, 2023

This is an E log book to discuss our patients de identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

CHEIF COMPLAINTS

- Pedal edema since 3 months

- Shortness of breath since 5 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently alright 9 years back when she went for a general checkup as she felt lightheaded then she was diagnosed with diabetes (type 2) and hypertension.

Then 5 years ago she had recurrent episodes of dizziness which were associated with non projectile vomitings and photophobia.

No H/O Fever

No H/O of meningeal signs

No H/O of abdominal pain, distention, constipation, diarrhoea

She was treated in a local hospital with unknown medication after which the problem recurred after 5-6 days.

She then came to our hospital where they treated her and discharged her with the following medications:

↠ Clopidogrel 75 mg

↠ Betahistine

↠ Aspirin

Then 3 months ago she developed bilateral pedal edema, pitting type (grade 4) with gradual progression till the thighs of the patient.

Since the past 5 days, she has had a complaint of shortness of breath which was grade 4 and is also accompanied with sweating and palpitations.

Urine output has been reduced since 5 days with associated back pain.

She was rushed to a local hospital but the treatment offered no relief after which they were referred to a higher centre where the investigations showed pericardial effusion and grade 2 CKD changes. She then came to our hospital for further treatment.