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43F Patient came to opd with c/o Bilateral pedal edema

This is an 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 patient's clinical problems with collective current best evidence based inputs. 



43F Patient came to opd with  c/o  Bilateral pedal edema since 1 month. 

Patient was apparently asymptomatic till 1 month ago then she developed c/o B/L pedal edema (pitting type, extending upto the knee) and chest discomfort (now subsided) now patient has c/o tingling of Rt. Upper limb.

Pt has come for regular checkup of HTN& DM

Had H/o UTI 1 month ago

Numbness in Rt upper limb and Rt lower limb since 1 month.

PAST HISTORY:k/c/o Diabetes since 10 yrs and is on Insulin HAI 15U- 20U- 25U.
k/c/o hypothyroidism since 6 yrs and is on Tab. Thyroxine 125mg PO/OD
k/c/o Hypertension since 2 years and Tab. Cilindipine 10mg+ Tab. Metoprolol 50mg PO/OD+ Tab. Olmesartan 70mg PO/OD
N/K/C/O CAD, CVA, TB, Asthama, Epilepsy.

PERSONAL HISTORY: normal appetite, mixed diet , inadequate sleep, normal bladder and bowel movement, no addiction.
FAMILY HISTORY: not significant

GENERAL EXAMINATION:-

The patient was examined in well lit room after taking his consent.

The patient was conscious, coherent and co operative. He was well Oriented to time, place and person

No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy. Edema present (Pitting type)

On examination:-
The patient is conscious, coherent and cooperative.
BP- 160/90
Temp- 97.2F
Pulse- 88 BPM
RR- 18

Systemic examination:
CVS:- S1, S2 heard, no murmus
CNS- NFND
RS- BAE+, NVBS
P/A- Soft, Non Tender, No organomegaly

Investigations:-

Serology:-

FBS:
PLBS:



Diet :-
Date:- 08/10/2023

Time.    Values.    Medication.      Food.  + Qty  
             (Mg/dl).                                            (gm)

8AM.       140. Metformin 500mg Godama rice
                         Glimiperide 1mg.     ~150gm
                         Nicardia 20mg
                         Thyronorm 125mcg


10AM.     119   


1PM.        181.  Metformin 500mg       Foxtail 
                           Nicardia 20mg.            Millets
                           Thyronorm 125mcg.  ~100gm

3PM.        170


8PM.        176.  Metformin 500mg       Wheat 
                           Nicardia 20mg.            Upma
                                                                ~100gm


10PM.     Missed

Date:- 09/10/2023

Time.    Values.    Medication.      Food.  + Qty  
             (Mg/dl).                                            (gm)

8AM.       207. Metformin 500mg    Ragi Dosa
                         Glimiperide 1mg.       ~100gm
                         Nicardia 20mg
                         Thyronorm 125mcg

10AM.     Missed


1PM.        194.  Metformin 500mg       Arekalu
                           Nicardia 20mg.            Millets
                           Thyronorm 125mcg.  ~100gm

3PM.        119


8PM.        205.  Metformin 500mg       Millets
                           Nicardia 20mg.            Dosha
                                                                ~100gm

10PM.     173

Date:- 10/10/2023

Time.    Values.    Medication.      Food.  + Qty  
             (Mg/dl).                                            (gm)

9AM.       172. Metformin 500mg  Fruits Apple,
                         Glimiperide 1mg. Pomegranate 
                         Nicardia 20mg.        ~120gm
                         Frusemide 20mg
                         Thyronorm 125mcg

11AM.     205   


1PM.        164.  Metformin 500mg      Millets
                           Nicardia 20mg.        Red sorrel
                           Thyronorm 125mcg.  ~100gm
                           Frusemide 20mg

3PM.        199


8PM.        155.  Metformin 500mg       Millets
                           Nicardia 20mg.            Dosha
                                                                ~100gm

10PM.     151

Dt:- 11/10/2023


Time.    Values.    Medication.      Food.  + Qty  
             (Mg/dl).                                            (gm)

7AM.     111.    Metformin 500mg           Idly 
                          Glimiperide 1mg.  
                          Nicardia 20mg.            ~100gm
                          Frusemide 20mg
                          Thyronorm 125mcg


9AM     251

BP Readings:-

1. Dt:- 08 October 2023 152/79 mm Hg
2. Dt:- 09 October 2023 167/84 mm Hg
3. Dt:- 10 October 2023 163/88 mm Hg
4. Dt:- 11 October 2023 155/81 mm Hg
5. Dt:- 12 October 2023 154/80 mm Hg
6. Dt:- 13 October 2023 161/86 mm Hg
7. Dt:- 14 October 2023 172/98 mm Hg
8. Dt:- 15 October 2023 154/96 mm Hg
9. Dt:- 17 October 2023 177/98 mm Hg
10. Dt:- 20 October 2023 170/94 mm Hg


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