40yr old female with facial puffiness and pedal edema

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R.Navya 

9th sem

Roll No:112

A 40 year old female came to the opd with 

*chief complaints of:-

-Facial puffiness since one month

-Pedal edema since one month

-SOB since one month 

*History of present illness:-

Patient was apparently asymptomatic 1 year back,she had similar conmplaints like FACIAL PUFFINESS,PEDAL EDEMA went to local hospital said to have LOW HB -6.5 gm/dl-she was put on oral medication.

Patient used medication for 2 months, HB improved to 10gm/dl

She has similar complaints since one month FACIAL PUFFINESS,PEDAL EDEMA,SOB- which is insidious in onset,Non progressive GRADE 2(Acc to NYHA). 

Not associated with orthopnea and PND.

H/O Weight gain present,

Dry skin present, 

Cold intolerance present. 

NO H/O Constipation,Fatigue, Menstrual disturbances.

NO H/O Decreased urine output,Fever,cold,cough,pain abdomen.

*Past History:-

No H/O DM,HTN,TB,BA,Epilepsy

*Family History:- Daughter k/c/o : hypothyroidism since 2015 and on medication THYRONORM 50 mg /od 

*Personal History:-

Diet:- Mixed

Appetite:- Normal

Sleep:- Adequate

Bowel and Bladder Movements:- Regular

Addictions:- Absent

*General Examination:-

On examination patient is conscious, coherent, cooperative.Moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy. 

Pedal edema present.

*Vitals:-

Temp-98.4 degrees F 

PR-80 Bpm 

RR-20 Cpm 

BP:100/60mm Hg

Spo2-99%@ RA

GRBS-92 mg/dl

*Systemic Examination:-

-Per Abdomen:-

No tenderness

-Resp system:-

Bilateral air entry is present.

Normal vesicular breath sounds are heard.

-CVS:-

S1S2+ 

-CNS:-

Normal

*Clinical Images:-

*Investigations:-

*Hemogram:-

Hb-11.3

Tlc-7600

PCV-32.9

MCV-95.6

MCH-32.8

RBC COUNT-3.44

Ptc-2.72

*CUE:-

Normal

*Serum creatinine:-0.9

*LFT:-

T.bil-0.14

D.bil-0.20

AST-34

ALT-27

ALP-88

T.protein-8.4

Albumin-4.93

A/G-1.42

*Thryoid Profile:-

 On 10/02/22

On 11/02/22

*X-ray:-

*ECG:-

*Provisional Diagnosis:-

Denovo diagnosed ? Primary HYPOTHYROIDISM.

*Treatment:-

Tab. THYRONORM 75 MG OD