42 year old female came to general medicine opd with chief complaints of pedal edema

Hi, I am Gaddam shreya 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 42 year old female patient who is housewife and does household chores came  to general medicine opd with chief complaints of pedal edema.

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic one month back. Then she noticed pedal edema, vomiting and visited local hospital and serum creatinine level observed is 4.5mg/dl. 15 days back she went to local hospital again as the symptoms are not reduced. Then she was referred to hospital in  Hyderabad.There they observed serum creatinine level raised to 14.4mg/dl, then she was suggested to start dialysis. 
One sitting of dialysis done on 14/12/22.
On 15/12/22  AV fistula surgery for dialysis is done.
Then again on next day i.e 16/12/22 another sitting of dialysis done .
They visited this hospital on 19/12/22 for dialysis.

PAST HISTORY 
4 years back patient developed weakness and fainted .
So she visited hospital and there they observed serum creatinine level raised to 3.4mg/dl along with increased blood pressure.
Not a known case of Diabetes.
No TB,epilepsy,asthma,CAD


FAMILY HISTORY - no relevant family history

PERSONAL HISTORY
Diet- mixed
Appetite - normal
Bladder and Bowel movement - regular
Sleep -adequate
No history of addictions

ALLERGIC HISTORY - No known allergies

DRUG HISTORY
She is on regular medication with 
Nodosis- 50mg
Mega-3
Metol AM 50 for hypertension.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor 
No icterus
No general lymphadenopathy
No clubbing of fingers 
No Pedal edema


VITAL SIGNS-
Temperature: 98.6F
Pulse:70bpm
BP: 160/80mm of hg 
Respiratory rate: 14cpm
SpO2: 98 percent
GRBS-110mg%

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
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
      no neck stiffness
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

PROVISIONAL DIAGNOSIS
Acute kidney injury 

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