GENERAL MEDICINE CASE STUDY

A 50 yr old female who is a agricultural labourer came to OPD with complaints of bilateral pedal edema, shortness of breath and chest pain.

Cheif complaints
Chest pain
Shortness of breath
Bilateral pedal edema

History of present illness
She was apparently asymptomatic 4 days back and developed pain in the chest which was non radiating type  and not associated with sweating and palpitations
Bilateral pedal edema( pitting type upto knees)
No aggregating and relieving factors

History of past illness
She was known case of hypertension and on irregular medication .
No h/o diabetes mellitus,TB, epilepsy,asthma.
Hysterectomy 15 yrs back 

Personal history
Married
Diet : mixed
Appetite: normal
Bowels : regular
Micturition is abnormal increased frequency of urine.
No known allergies

Family history
No f/ h/o diabetes, hypertension,TB ,asthma, epilepsy.

General examination
No palor
No cyanosis
No icterus
No lymphadenopathy
No clubbing
No malnutrition 
Bilateral pedal edema is present

Systemic examination
CVS
S1,S2 are heard
No thrills
No cardiac murmers

Respiratory system
Dyspnea is present
No wheezing
Position of trachea is central
Breath sounds are vesicular

Abdomen
Shape : obese
No tenderness
No palpable mass
No bruits 
Hepatomegaly and splenomegaly are absent

CNS
Patient was Conscious and coherent 
Speech : normal 
No neck stiffness
No kernigs sign
Cranial nerves ,motor system,and sensory system are normal.

Provisional diagnosis
Hypertension urgency

INVESTIGATIONS:


Treatment
TAB PAN 40 mg
TAB NAPROXEN 250 mg
TAB LASIX 40 mg
TAB LEVOCETRIZINE 5 mg

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