A 75 yr old female

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

A 75 yr old female resident of Miryalaguda came to the opd witb the chief complaint of decreased urination and pedal edema  since 4 days 

HISTORY OF PRESENT ILLNESS

Pt was apparently symptomatic 4 days back then she developed severe itching due to mosquito bite following which she scratched that resulted in bleeding and she used hot water to wash the area then she had a feeling of something crawling on the leg . She has pedal edema since then 
She has decreased urine output for 3 days and no urination for one day 

 DAILY ROUTINE 
She wakes up at 7 am and does her personal activities 
and makes tea and makes rice and curries for hersel and her husband and eats at 9 Am and then does her house work that include sweeping and laundry of the clothes and takes her lunch at 2 pm ( most of the times she skips when she eats breakfast at 11 am ) and sleeps from 2:30pm to 4:30 pm and wakes up and makes tea for both of them and talks to neighbours till 8 pm . She takes her dinner at 8:30 pm and sleeps at 9:30 pm 

    

     
          



PAST HISTORY 
10 yrs back She had heavy bleeding for one month ( first 3 weeks – 2-3 times per week ; last week continuously) .
She went hospital in guntur and underwent scanning and was diagnosed as having fibroids . Then she have undergone hysterectomy in the same hospital 
N/k/C/O diabetes, HTN , epilepsy, TB, Asthma, 
 
PERSONAL HISTORY 
Married 
Appetite- Normal 
Non-vegetarian 
Bowel movements - regular 
Micturition - abnormal 
No known Allergies 

FAMILY HISTORY 

 No significant family history 

GENERAL EXAMINATION 

Pallor - absent 
Icterus - absent 
Clubbing - absent 
Cyanosis  - absent 
Lymphadenopathy - absent 
Pedal edema - present ( lt>rt lower limb ) 
 
VITALS 
Temperature- 98.6C/F
Pulse rate - 88/ min 
Respiratory rate - 16/min 
BP - 110/70 mm/hg 
SPO2- 98%
GRBS - 106 mg%

SYSTEMIC EXAMINATION 
CVS 

No thrills 
No murmurs 
Cardiac sounds S1S2+

Respiratory system 

No dyspnoea
No wheeze 
Position of trachea - central 
Breath sounds - vesicular 

ABDOMEN 

obese 
No tenderness 
No palpable mass 
Hernial orifice - normal 
No free fluid 
No bruits 
Liver - not palpable 
Spleen - not palpable 

CNS 
Conscious
Speech is normal 
Signs of meningeal irritation - no neck stiffness 
                                                No kernigs sign 
Cerebral signs 

Finger- Nose in coordination- NO 
Knee- heel in coordination 

PROVISIONAL DIAGNOSIS 
Acute kidney injury with cellulitis 



INVESTIGATIONS

     




   




     
     


     
    
    

 
     


1/8/22 
  
     
   
  



     





 TREATMENT 

1) Inj.MEROPENEM - 500 mg/IV/TID
2)Inj.AUGMENTIN - 1.2 g IV/BD
3) Inj.METROGYL - 500mg IV/TID 
4) Inj.NAHCO3 meq IV/stat 
5) T.CHYMEROL FORTE PO/TID
6) Magnesium sulphate dressings 
 7) strict lower leg elevations 
 


























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