A 86yrs old female patient presented with CHIEF COMPLIANTS of Pedal edema in left leg since 12days and decreased urine output since 12 days
HOPI
Patient was apparently asymptomatic 12days back then she had severe itching on left leg following mosquito bites and scratched that resulted in blister formation,then she applied Hot water on blisters,then she had pedal edema since then and urine output is decreased.
PAST HISTORY
Not a k/c/o HTN,TB,DM,EPILEPSY, ASTHMA.
No Previous surgeries
TREATMENT HISTORY
No relavent treatment history
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Mixed Diet
Appetite Normal
Bowel&Bladder movements are Regular
Sleep Adequate
No Addictions
No known allergies.
GENERAL EXAMINATION
Patient was conscious, coherent well oriented to time,place , person.Well built and moderately nourished.
NO PALLOR
NO CYANOSIS
NO ICTERUS
NO CLUBBING
NO GENERALISED LYMPHADENOPATHY
PEDAL EDEMA
VITALS::
TEMP AFEBRILE
PR 70bpm
RR 12cpm
BP 120/80mmHg
SYSTEMIC EXAMINATION
1.CVS
**S1 ,S2 heard
**No murmurs.
2.Respiratory system
**Dyspnoea- No
**Wheeze -No
**Position of trachea-Central
**Breath sounds-vesicular
3.ABDOMEN
**Shape of abdomen-scaphoid
**Tenderness-No
** Palpable mass-No
** Liver- Not palpable
**Spleen - Not palpable
**Bowel sounds - No
4.CNS
** No abnormalities detected
Provisional diagnosis : Acute Kidney Injury with cellilitis