A 60 year old female with facial puffiness, pedal oedema and knee joint pains
Hello, I am Harshitha Shalini , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
USG
A 60 year old female, who was an agricultural labourer by occupation (but has stopped working since 4 years), came to the hospital with
CHIEF COMPLAINTS -
pain in both knees since 4-5 years, facial swelling since 2-3 months, pedal edema since 1 week.
HOPI-
The patient was apparently asymptomatic 4-5 years ago. She then started developing pain in both her knees which is aggravated on walking and standing, relieved on resting and medications (painkillers). She stopped working due to the pains.
2-3 months ago, she developed facial puffiness which was insidious in onset and gradually progressive in nature. It appears maximally in the mornings and gets relieved by the end of the day.
1 month ago, she had a tooth extraction on the left side and still has facial puffiness on the left side.
1 week ago, she had pedal edema upto her ankles which was pitting in nature. This also appears maximally in the morning and subsides by the end of the day. Her edema greatly subsided by itself after a week.
She came to the hospital now to find a working solution for her joint pains and to find out about why her pedal edema appeared and disappeared.
DAILY ROUTINE:-
The patient wakes up in the morning at 5:30 and does household work, eats breakfast at 8:00. She smokes tobacco at this time.
She then passes her time by talking with family members or guests till 11:00, when she cooks her lunch and eats lunch late, around 3:00-4:00pm
She will have tea occasionally in between, when she visits family. She spends time sleeping or talking with friends and family in person or on the phone.
At night, as she doesn't feel hungry, she sleeps at around 10:00pm.
She smokes (chutta) 3 times a day, 1 chutta at a time and started smoking 2 years ago.
She takes alcohol occasionally and she started taking alcohol 40 years ago
This has been her routine since 4 years, after she stopped working.
PAST HISTORY:-
Not a known case of diabetes, hypertension, CVA, CAD, TB, asthma
FAMILY HISTORY:-
Not significant.
TREATMENT HISTORY:-
The patient has a history of using NSAIDS 3-4 days a week since 4 years for the joint pains, suggested by RMP.
PERSONAL HISTORY:-
Appetite: normal
Diet: mixed
Sleep: adequate
Bowel movements: regular
Micturition: normal
No known allergies
Addictions: Smokes tobacco once or twice a day everyday
MENSTRUAL HISTORY:-
Attained menopause 20 years ago
GENERAL EXAMINATION:-
The patient is conscious, coherent, cooperative, moderately built and well-nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy
Pedal edema present in right foot (grade 1)
Vitals:-
Temperature: Afebrile
Blood pressure: 120/80mm Hg
Pulse rate: 82 bpm
Respiratory rate: 18cpm
SYSTEMIC EXAMINATION:-
CNS: Patient is conscious, coherent and cooperative, well-oriented to time, place and person
CVS: S1, S2 sounds heard, no murmurs
Respiratory system: trachea central, normal vesicular breath sounds heard, no added sounds
Abdomen: distended, no palpable organs.
INVESTIGATIONS:
ECG
PROVISIONAL DIAGNOSIS:-
Facial puffiness under evaluation
TREATMENT:-
Potassium citrate and magnesium citrate taken
Aspirin
Rosuvastatin
Furosemide
