Gm case ..

Case scenario...
Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio 

                  CASE HISTORY
Case sheet:
A 57 year old female resident of
Choutappal
Chief complaint:
- decrease in urine output
- pedal oedema
-puffiness  of face
History of present illness:
Patient was apparently asymptomatic then  she started developing puffiness of face since 1 month also started developing pedal oedema.Initially started in lower limb and gradually progressed to knee
- decrease in urine output since 1 week.
Negative findings:
No fever
No burning Micturition
History of past illness:
K/C/O. Hypertension since 15 years
Diabetes mellitus since 15 years.
Personal history:
Married
Appetite:normal
Diet: mixed
Bowels: normal
Micturition: low
Known allergies: no
Family history:
Not significant
General examination:
Pallor: no
Icterus: no
Cyanosis: no
Lymphadenopathy: no
Malnutrition: no
Vitals:
 Temperature: 98.4 F
Pulse rate : 88/ min
Respiratory count : 18/ min
Bp: 120/80
SpO2: 99%
Systemic examination:
1.Cardio vascular system
No thrills
Cardiac sounds heard
Cardiac murmurs: no
2.Respiratory.
No dyspnoea
No wheeze
3.Abdomen
Tenderness: no
Palpable mass: no
Free fluid: no
Bruits: no
Liver: not palpable
Spleen: not paplable
Bowel sounds: no
4. CNS
Patient was conscious, coherent.
Speech : normal
Neck stiffness: no
Provisional diagnosis:
 Renal related disease 
Diabetic nephropathy ..

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