65 year old female with burning sensation of whole body,SOB,pedal Edema, giddiness

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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Presenting complaints

Patient came to the GM OPD with the chief complaints of burning sensation of whole body since 5 days

Shortness of breath since 5 days

Swelling of lower limbs

Giddiness since 5 days

Patient was apparently asymptomatic 7years ago then she had pedal Edema which is pitting type relieved by taking medication.

Burning sensation of whole body since 7years but aggravated since 4days relieved with wetting the body with wet cloth.

Shortness of breath since 5 days grade 2 NYHA relieved by taking rest.

No orthopnea,No PND

Giddiness since 5 days.No postural variation.No tinnitus.

No hearing loss

No decreased urine output

Past history

K/C/o DM type 2 since 8years uses Glipizide 5mg po/of

HTN since 8years uses Telma 40 mg po/od

K/C/o CAD 8 years ago PTCA done

N/K/C/o TB, Epilepsy, Thyroid disorders

K/C/o heart failure with pEF, complicated UTI with stricture urethra S/P heagers dilation 

Personal history

Daily routine

She wakes up at 6-7am then she will have her breakfast at 9am

At 1pm she has her lunch

At 6 pm she has her dinner then at 8pm she sleeps

Appetite decreased

Sleep inadequate

Bowels constipation present passes stools after having medicine

Micturition increased in night 5-6times 

General physical examination

Patient is conscious coherent and cooperative

PR 80 bpm

BP 140/80mm hg

RR 22 cpm

SpO2 98%at RA

GRBs 125mg/DL

No pallor, icterus, cyanosis, clubbing, lymphadenopathy

Bilateral pitting type Edema 

Systemic examination

CVS pansystolic murmur at aortic pulmonary mitral areas

RS Bilateral air entry present NVBS

Per abdomen

Soft ,non tender

CNS-NFND

Diagnosis

Heart failure secondary to CAD

Chronic kidney disease

Treatment

Tab lasix 20mg po/BD

Tab ecospirin av 75 po h/s

Tab Glipizide 5mg po/od

Tab Telma 40 mg po/od

Tab pregaba 75mg po h/s