55/F with Pedal Edema, SOB, Itchy skin lesions





 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.

A 55 year old woman, resident of and by occupation has come with the complaints of pedal edema, shortness of breath and itchy skin lesions since 1 week 

History of presenting illness : 

Patient was apparently asymptomatic 1 week ago, then she had pedal edema which is of pitting type upto the knee. 

She complains of shortness of breath since 1 week (Grade 2 MMRC) relieved on taking rest. No orthopnea and no PND 

Itchy skin lesions over extensor surface of bilateral hands and feet. 

Photosensitivity +

Lesions are present only on the sun exposed areas 

C/o hesitancy , dribbling of urine , decreased urine output 

Burning micturition since 1 week 

Cough since 5 days 



Daily Routine : 


The patient is a farmer by occupation. 

She wakes up at 5 AM in the morning and has  breakfast by 8 AM , finishes her daily chores and leaves for work. 

Usually has lunch by 1 PM 

Returns home by 4 pm in the evening 

She has a cup of tea with 2-3 biscuits at around 5 pm 

She has dinner by 9 pm and goes to bed by 11 pm 


Past History : 


Not a known case of Hypertension, Diabetes, Asthma, Epilepsy, Tuberculosis, Thyroid disorders. 



Personal History :


Sleep : Normal 

Diet : Mixed 

Appetite : Normal 

Bowel and Bladder Movements : Regular 

Addictions : none 


Family History : 


No similar complaints 


General Examination: 

 

Pallor - absent 

Icterus - absent 

Cyanosis - absent 

Clubbing of the fingers - absent 

Lymphadenopathy - absent 

Pedal Oedema - absent 

Vitals : 

BP - 120/70 nnHg

PR- 68 bpm 

RR - 20 cpm

GRBS - 121 mg/dl

Systemic examination : 

CVS - S1 S2 heard  no murmurs 

Respiratory- bilateral air entry present 

Cns - no focal neurological deficit 

Abdomen - soft, non tender 





Investigations : 


2D echo : 


Treatment :

TAB LASIX 40 mg PO/BD 

TAB OROFER XT PO/OD 

TAB ZINCOVIT PO/OD

LIQUID PARAFFIN PO/OD


Discharge summary : 











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