General medicine
Hi ,I'm Rama Krishna Dega 3rd semester medical student.this is an elog book to discuss our patients health deta after taking this consent. This also reflects my patient centered online learning portfolio
CASE SHEET:
78 year old female patient presented with reduced urine output & generalised swelling
78 year old female farmer from Miryalguda was admitted into the hospital on 11-07-2022.
Chief complaints:
78 year old female was admitted into the hospital with cheif complaints of swelling of left lower limb since 4 days, blister on left lower limb since 3 days & decreased urine output since 4 days.
History of present illness:
Patient was apparently asymptomatic 4 days back & then she had severe itching due to mosquito bite, following which, she scratched that which resulted in bleeding & she used hot water to clean that area & she noticed blister on left lower limb 3 days back. She also developed bilateral pitting type of pedal edema of both the lower limbs & associated with local rise in temperature of both lower limbs. And decreased urine output since 4 days
SOB present
No history of fever
No history of Vomitings
No history of diabetes
No history of HTN.
No history of allergies
Past history:
She had undergone with hysterectomy
N|K|C|O HTN, DM, epilepsy, asthma, TB
Family history:
Not relevant
Drug history:
Nil
Personal history:
Diet : Mixed
Appetite : normal
Sleep: Adequate
Addictions : Nil
Bowel/ bladder: regular bowel movements/ decreased urine output
Allergies: nil
General examination:
Consious coherent cooperative
Moderately built
Moderately nourished
No pallor
No Icterus
No Cyanosis
No clubbing of finger
No lymphadenopathy
Pedal edema present - bilateral pitting type
Vitals:
Temperature - 98.6 F
Pulse rate - 88 /min
Respiratory rate - 16/min
Blood pressure- 110/70 mm Hg
SpO2 - 98%
GRBS - 106 mg/dl
Systemic Examination:
A. Cardiovascular system -
No thrills
No cardiac murmurs
Cardiac sounds: S1 & S2
B. Respiratory system -
No dyspnea
No wheezing
Vesicular breathe sounds
C. Abdomen -
Obese
No tenderness
No palpable mass
Reports:
After 3 days of dressing :
Provisional diagnosis :
Chronic renal failure
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