A 48 year old woman with abdomen distension and decreased urine output
General Medicine Case Discussion
June 06, 2023
General medicine case discussion
E LOG MEDICINE CASE
06/06/2023
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.
Name : U.Sri Vidya
Roll no : 121
2020 Batch
I''ve been given this case to solve in an attempt to understand the topic of "PATIENT CLINICAL DATA ANALYSIS" to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and comeup with Diagnosis and Treatment plan.
CASE DISCUSSION
Date of admission: 03-06-2023
A 48 year old female patient came to medical OPD with
Chief Compliants -
- abdomen distension since 6 days
- SOB and pedal edema since 5 days
- decreased urine output since 1 day
History of presenting illness -
Patient was apparently asymptomatic since 6 days back, then she developed abdominal distension followed by
SOB , pedal edema and oliguria.pedal edema is bilateral which is of pitting type since 5 days.
Past history -
K/c/o DM since 10 years
She showed similar symptoms of abdominal distension,pedal edema,SOB, decreased urine output 2 years back
No known history of HTN , EPILEPSY, THYROID,CAD.
No surgical history.
Personal history -
Appetite - lost
Sleep - Adequate
Diet - Mixed
Bowel and bladder movements - Regular
Allergies - None
Addictions - None
Family history -
No significant family history.
Drug history
Metformin since 10 yrs
Physical examination
General examination
Patient is Conscious Coherent and co
Coordinated
Well oriented to time, place and person
Moderately built
Moderately nourished
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing of fingers - Absent
Lymphadenopathy - Absent
Generalized edema - Present
Vitals
Temperature - febrile
Pulse- 89 bpm
Systemic examination
Cardiovascular system
No thrills
Cardiac sounds : s1 & s2 heard
No cardiac murmurs
Respiratory system
Central trachea
Dyspnea- present
No wheezing
Abdomen
Distended
Tenderness present
No palpable mass
No palpable liver and spleen
Bowel sound heard
Vitals -
Temperature - febrile
Pulse- 89 bpm
Investigations
