78 years old female patient with Chronic Kidney Disease

78 year old female patient presented with reduced urine output & generalised swelling

Hi, I’m Hruthik, 3rd sem medical student. This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking her consent.

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:


When she came to casualty
After 3 days of dressing 
Provisional diagnosis :
Chronic renal failure

Comments

Post a Comment

Popular posts from this blog

A 75 year old patient with osteoarthritis

Image
 75 year old male with Bilateral Osteoarthritis Hi, I’m Hruthik, 3rd sem medical student. This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his consent. 75 year old Male farmer from Mothukuru was admitted into the hospital on 27-06-2022.  Chief complaints: 75 year old male was admitted into the hospital with cheif complaints of weakness and pain in his lower back since 3 months and swelling of both his legs since one month.He was unable to move or lift both his legs.  Patient also complained of knee joint pain and burning micturition.  History of present illness: Patient was asymptomatic 3 months ago then he developed lower back pain( gradually progressive), radiating to his lower limbs associated with numbness and bilateral non pitting type of edema. He faced difficulty in walking because of the back pain but the pain relieved on rest.  SOB absent  No history of fever  No history of Vomitings No history of
Read more

A 65 year old patient with iron deficiency anemia

Image
General medicine 1 A 65 year old male patient with iron deficiency anemia November 06, 2022 November 7 , 2022 E LOG GENERAL MEDICINE  Hi, I am G . Hruthik 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.   *  This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration. Chief complaints :  A 65 year old male farmer from nagarjuna sagar came with  cheif complaints of : Dizziness and decreased appetite from 5-6months Pedal edema and facial puffiness since 1 week. History of present illness : Patient was apparently asymptomatic 6 months ago,then he developed dizziness
Read more

18 year old female came with swelling in front of the neck

Image
1 Nov , 2023 E LOG GENERAL MEDICINE  Hi, I am G. Akshara , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.  * This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration. Chief complaints :  A 18 year old female , resident of sirikonda , agricultural worker by occupation , came to the OPD with chief complaint of swelling in front of the neck slightly towards right side since 8 years.   History of present illness :  Patient was asymptomatic 8 years back, and then noticed a swelling in front of the neck which was  Incidious in onset , gradually progressed to presen
Read more