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

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