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


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