20 year old female with bilateral pedal edema and shortness of breath

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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 those patient's clinical problems with collective current best evidence based inputs.

This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

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 to come up with a diagnosis and treatment plan.

Sanjana Kulakarni

1801006152

A 20 yr old girl came to the casualty with chief complaints of  -

Pedal edema since 15 days

Hyperpigmented macules since 15days

Fever since 15 days

Cough(dry)since 7 days

Decreased appetite since 7 days

Shortness of breath since 5 days

Decreased urine output since 3 days

Abdominal distension since 1 day

Loss of ability to speak since 1 day

History of present illness -

Patient was apparently asymptomatic 15 days back then she developed bilateral pedal edema extending till knees which was insidious in onset, gradually progressive with no aggravating and relieving factors, for which she took some medication following which she developed hyperpigmented macules on her face. She stopped taking medication after development of macules on her face. 

After 2 days of stopping medication she again complained of developing bilateral pedal edema.

Along with pedal edema she developed fever which was high grade, continous in nature, associated with chills since 5 days with no history of evening rise of temperature, no headache, no sweating. 

Then she developed abdominal distension 8 days back which was insidious in onset and gradually progressed to present size. 

Following this, she developed cough, which was insidious in onset, non productive and relieved on medication.

Then she developed decreased appetite one week back.

Later, 5 days back, she developed shortness of breath which was insidious in onset, progressive in nature, to which she got admitted in other hospital and then she was referred to this hospital. 

She also had history of constipation and decreased urine output since 3 days. 

Past history -

No similar complaints in the past 

She is not a known case of diabetes mellitus, hypertension, asthma, thyroid, coronary artery disease, epilepsy, TB

Personal history -

Mixed diet

Appetite lost

Non veg diet

Decreased bowel and bladder movements

Family history -

No significant family history

On Examination -

Patient was Conscious, coherent, non cooperative well oriented to time, place and person. 

On admission vitals are :

RR : 24 cpm

BP : 110/70 

PR : 110 bpm

Sp02 : 97%

Temp : 99.8

On Respiratory system examination -

On inspection - 

Normal shaped chest, trachea appears to be in centre, no scars and sinuses present, abdomino-thoracic type of respiration, normal respiratory movements present

On palpation -

All inspectory findings are confirmed on palpation.

On percussion - 

On auscultation -

Normal vesicular breath sounds heard along with inspiratory wheeze heard in all areas and left infrascapular crepts present.

On CVS examination -

Raised JVP, apex placed laterally, palpable thrill in Mitral area, loud S2 heard, pansystolic murmur in mitral area.

Per abdomen -

Soft and nontender, central umbilicus. 

On CNS examination -

Right Handed person, studied upto 11th standard.

Higher mental functions -

Conscious, oriented to time place and person.

MMSE 17/30

Speech : 

Behavior :

Memory : Intact.

Intelligence : Normal

Lobar Functions : 

No hallucinations or delusions

Cranial nerve examination -

1st : Normal

2nd : visual acuity is normal

          visual field is normal

          colour vision normal

           fundal glow present.

3rd,4th,6th : pupillary reflexes present.

      EOM full range of motion present

       Gaze evoked Nystagmus present.

5th : sensory intact, motor intact

7th : normal

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal

Motor examination:-

                          Right                         Left

                   UL           LL            UL           LL

   BULK Normal Normal Normal Normal

   TONE hypertonia hypertonia hypertonia hypertonia           

   POWER       5          5              5              5

   Superficial reflexes:-

   CORNEAL  present                  present       

   CONJUNCTIVAL present          present

   ABDOMINAL present

   PLANTAR withdrawal     withdrawal

Deep tendon reflexes:-

                                          R                    L

   BICEPS                         2+                   2+

   TRICEPS                      2+.                    2+

   SUPINATOR                 2+                    2+

   KNEE                             4+                    3+

 

   ANKLE                          2+                   2+

Patellar clonus present right side:- 4+

                                            Left side:- 3+

Sensory examination-

Spinothalamic examination 

Crude touch

Pain

Temperature

Dorsal column sensation -

Fine touch

Vibration

Proprioception

Cortical sensation -

Two point discrimination

Tactile localisation.

Steregnosis

Graphasthesia

Cerebellar examination -

   Finger nose test

   Heel knee test 

   Dysdiadochokinesia

   Dysmetria

   Hypotonia with pendular knee jerk            present.

   Intention tremor present.

   Rebound phenomenon 

   Nystagmus

   Titubation 

   Speech

   Rhombergs test

Signs of meningeal irritation: absent

Gait: hemiplegic gait, wide based with reeling while walking, unsteady with a tendency to fall

Unable to perform tandem walking.