A 55 year old female came to general medicine opd with chief complaints of generalised edema and decreased urine output
Hi, I am G.Anisha of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of her condition.
A 55 year old female patient who is housewife and does household chores came to general medicine opd with chief complaints of generalised pedal edema and decreased urine output.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 years ago. Then she noticed blurred vision in both eyes. She consulted a local doctor and he referred to other doctor in Hyderabad.
There she was diagnosed with diabetic retinopathy and underwent a surgery for right eye and improved her vision and was told that her left eye vision can't be improved by surgery.
And 3 months back she developed bilateral pitting type of pedal edema which is gradually progressed to present till knees.
4 days back she visited a local doctor with complaints of generalised edema and decreased urine output. There they observed serum creatinine level raised to 3.5mg/dl. Then they referred to consult in kims.
2 days back patient visited general medicine opd with generalised edema and decreased urine output. Here, when they tested serum creatinine level was 4.1mg/dl. She was cross referred to opthalmology department.
PAST HISTORY
Patient is hypertensive and diabetic since 10 years.
Patient developed diabetes retinopathy 2 years ago.
No history epilepsy,TB,asthma.
FAMILY HISTORY - no relevant family history
PERSONAL HISTORY
Diet- mixed
Appetite - normal
Bowel movement - regular
Bladder movement - irregular
Sleep -adequate
No history of addictions
ALLERGIC HISTORY - No known allergies
DRUG HISTORY
She is on regular medication with
Telma 40mg for hypertension
Celipizide 60mg for diabetics.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
Pedal edema - PRESENT (pitting type)
VITAL SIGNS-
Temperature: 98.6F
Pulse:60 bpm
BP: 160/80mm of hg
Respiratory rate: 14cpm
SpO2: 98 percent
GRBS-159mg%
SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds
ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Free fluid present
Bowel sounds are not heard
CENTRAL NERVOUS SYSTEM
Conscious
Speech- normal
Signs of meningeal irritation -
no neck stiffness
no kerming's sign
Cranial system - intact
Motor system - intact
Sensory system - intact
Cerebeilar signs
Finger nose- in coordination
Knee heel - in coordination
PROVISIONAL DIAGNOSIS
Acute kidney injury associated with
INVESTIGATIONS
Serum creatinine, colour doppler 2d echo,ECG
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