75 yr old female with low back ache, pedal edema and sob.

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Case:-

75 yr old female came to the casualty with 

c/o low back ache since 4 days .

C/o bloating since 4 days,

 c/o shortness of breath since 4 days .

C/o b/l pedal edema since 10 days. 

HOPI:- 

Patient was apparently asymptomatic 10 days back , then she developed b/l pedal edema( pitting type) upto the knees associated with SOB (grade 2). No orthopnea/PND.

 Low back ache since 4 days, radiating to groin and went to nearby RMP and took medication, pain subsided on taking medication.

Decreased Appetite since 1 week.

No c/o decreased urine output, chest pain palpitations, nausea, vomiting.

Not a k/c/o DM, HTN, ASTHMA, EPILEPSY, TB.

ON EXAMINATION:- 

Patient was conscious coherent cooperative moderately built and moderately nourished.

 

Pallor - moderate

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals ;

Afebrile

Bp: 150/80 mm hg

PR: 77 bpm

RR: 24 cpm

Spo2: 95% @RA

Cvs:- 

S1,S2 heard, raised jvp, parasternal heave present.

RS:-

BAE present

Nvbs.

P/A:-

Obese, soft, non tender.

CNS:-

Patient was conscious, 

Speech - normal

No meningeal signs

Provisional diagnosis:-

Anaemia secondary to nutritional cause.

? Heart failure with preserved EF.

Treatment:-

1. Tab. Orofer XT po/of

2.Tab.pan-d po/of

3. Tab. Ultracet Qid

4.protein powder 2 tsp in 1 glass of water po/tid

5. Tab . Lasix 20 mg od ( if SBP >110 mm hg).

6.moniter vitals 4th hrly.

 Chest x-ray

x- ray LS spine

Ortho refferal:-