General Medicine - 8

11 November, 2022

A 32 YEAR OLD FEMALE CAME WITH BACK PAIN AND PEDAL EDEMA.

CASE SHEET:

Chief complaints:

A 32 year old female, labourers by occupation came with chief complaints of:
- back pain since 9 years
- bilateral pedal edema on and off since 1 month
- burning micturition since 7 days
- fever since 2 days

History of present illness:

The patient was asymptomatic 9 years back. She then developed lower back pain starting from buttock region, radiating upto neck, which was aggravated on bending and working, and relieved on rest and in prone positions and medication.

She then had complaint of Constipation since 2 months associated with pain in anal region.

She then developed bilateral , pitting type, pedal edema, which was on and off since 1 month, which was seen during episodes of back pain, which subsided on itself.

She also has a history of burning micturition since 7 days.

She also has a history of fever, associated with cold since 2 days.

Associated diseases:
Insignificant

Past history:

Hysterectomy done one year back.
- Not a known case of hypertension, diabetes,          tuberculosis, epilepsy, coronary artery disease.

Personal history:

Diet: Mixed
Bowel : constipation since 2 months
Micturition: Burning micturition 
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
Pedal edema

 VITALS:

Temperature: 97.8 F

Pulse: 62 beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 96%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

Investigations:
Complete blood picture
Liver function test:
Ultrasound:
ECG:
Provisional Diagnosis:
Low back pain under evaluation.

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