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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