General medicine case discussion

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NAME: Mamidi Harini 

Roll No: 66

CASE PRESENTATION:

A 20 year female resident of ramanapet house wife by occupation came to general medicine OPD (17 /12/22)with chief complaints of swelling of legs.

HISTORY OF PRESENTING  ILLNESS:

Patient was  apparently  asymptomatic 5 months back then she developed lesions all over body and healed with rashes.

Then patient developed generalized swelling of body starting initially with bilateral pedal edema then progressing to abdomen and then facial puffness. History of decreased urine output 

The patient went  to local hospital  and was treated .the patient now presented with bilateral pedal edema

HISTORY OF PAST ILLNESS : No history of cough ,vomiting, shortness  of breath 

No history of smiliar complaints in past 

No history of hypertension, tuberculosis, bronchial asthma.

PERSONAL HISTORY : 

Marital status :married

Appetite: normal

Diet : mixed

Bowel and bladder habits: regular 

Sleep: adequate 

Addictions : no Addictions

FAMILY HISTORY: 

Their is no significant family history. 

 

MENSTRUAL HISTORY:

 She attained age of menarche at 13 years and had regular 30 days menstrual cycle for 4 days

GENERAL EXAMINATION:

Conscious, coherent, co-operative

Moderately built,nourished.

 

PALLOR: PRESENT

ICTERUS:ABSENT

CYANOSIS: ABSENT

CLUBBING OF FINGERS/TOES: ABSENT

LYMPHADENOPATHY: ABSENT

PEDAL EDEMA: PRESENT.

 

VITALS: 

PULSE RATE: 86 bpm

BLOOD PRESSURE: 130 /80 mm of hg

SYSTEMIC EXAMINATION:

CVS:

S1,S2 Sounds heard,

No audible murmurs,

Thrills:No.

RESPIRATORY SYSTEM:

Dyspnea is present,

Position of trachea:central,

Normal vesicular breath sounds are heard,

No adventitious sounds  .

Per abdomen: soft and non tender

PROVISIONAL DIAGNOSIS:

Nephrotic syndrome .