General Medicine

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Name : J.Poojitha

Roll no: 52

CASE PRESENTATION:

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

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 months back then she developed pruritic lesions on bilateral lower limbs, because of itching she scrached the skin, on healing it got hyperpigmented.

Then patient developed generalized swelling of body 15 days back, starting initially with bilateral pedal edema then progressing to abdomen and then facial puffiness is developed. History of decreased urine output is present. 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 diabetes, hypertension, tuberculosis, bronchial asthma, epilepsy. 

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

160/90 mm of hg

SYSTEMIC EXAMINATION:

CVS:

S1,S2 Sounds heard,

No audible murmurs,

Thrills:No.

RESPIRATORY SYSTEM:

Dyspnea is absent

Position of trachea:central,

Normal vesicular breath sounds are heard,

No adventitious sounds .

Per abdomen: soft and non tender.

PROVISIONAL DIAGNOSIS: nephrotic syndrome

Investigations