A 20 year female with pedal edema and decrease bowel & bladder movements

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This is an online E - log book to discuss our patients 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. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.


28/9/2022

A 20 year female came with chief complaints of :
B/L pedal edema extending till the knees since 20 days
Abdominal distension since 8 days
Decreased bowel and bladder movements, decreased appetite, decreased width of opening mouth & intensity of sound, throat pain since 3 days

History of presenting illness:

Patient was apparently asymptomatic 1 month back

1 month ago she developed pedal edema grade 3 (upto knees) and burning pain on sole B/L
She went to local RMP for which she got treated and swelling and pain got reduced
At that time according to her father, her platelet count was around 2,56,000 and HB was around 8
No other abnormalities were detected at that time

Later, they visited a doctor just for a check up. He said there were no abnormalities except small lesion in heart for which he prescribed a medicine(unknown) for 2 months BD. When she took those prescribed tablets 1 day later she developed red, macular rashes all over the face. Then she stopped taking that medicine and 2- 3 days later red spots evolved into black spots

From that day she was weak and had decreased appetite

20 days ago, she was infused with 2 glucose bottles and that night she again developed pedal edema grade 3 (till knees)

8 days ago she developed abdominal distension and was breathless. She was able to breath only in sitting position. She used to sit on bed for a long time for this reason (SOB grade 3/4)

3 days ago there was decreased bowel and bladder movements, throat pain, decreased appetite, decreased width of opening mouth(she wasn't able to open mouth fully), decreased intensity of voice(tone of voice got reduced), fever - intermittent fever associated with chills and rigor, cough was non productive and more at evening times, no positional variation present, on and off

Yesterday they visited a private hospital.
Reports: 

Then later yesterday night, she was admitted to our hospital.

Past history

N/k/c/o HTN, DM, Thyroid disorders, CAD, Epilepsy, TB

Personal history

Not married
Non vegetarian
Student, studied till 12 th standard
Decreased appetite
Decreased bowel and bladder movements
No know allergies
No habits/ addictions

Family history

Not significant

Menstrual history

Age of menarche : 12 years
2 months of amenorrhea
Before 2 months
Frequency once every month
Normal duration and flow
Not associated with pain and clots

General examination

Patient was conscious, coherent and cooperative

PR - 122 bpm
BP - 120/80 mm Hg
RR - 30 cpm
SpO2 - 97% @ RA

Rashes over palm and sole:

Pedal edema - pitting type grade 3

Investigations:

28/9

Ultrasound:

Ophthalmology:

ENT:

Pulmonology:

Nephrology:

X ray

2D echo 1: 



https://youtu.be/3o3hx0fYWNo

Treatment:

28/9

Inj Agumentin 1.2 gm/IV/BD
Inj Lasix 40 mg/IV/BD
NEB Duolin and Budecord 6th hourly
Inj Neomol 1g/IV/SOS
Betadine gargling
Tab Azithromycin 500 mg PO/OD



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