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Health History and Physical Examination - Coggle Diagram
Health History and Physical Examination
Admitting medical diagnosis with pathophysiology process
Acute renal failure due to
sudden loss of the ability of the kidneys
to excrete wastes, concentrate urine, conserve electrolytes,and maintain fluid balance.
increased intra-tubular pressure
decreases glomerular filtration rate (GFR)
causing, acute urinary tract obstruction that can lead to impaired renal blood flow and inflammation.
Other current conditions
Hypertension
Diabetes Mellitus
Renal Tubular Acidosis
Chronic kidney disease
Hypovolemia
Diarrhea and vomiting
History of present illness
Constantly vomiting
Mild shortness of breath (SOB)
Diarrhea for three days with dark-coloured stool
Past history
Patient is not employed and staying with husband and son. Patient is concerned about having to miss housework and her child due to his illness. The patient does not smoke and drinks alcohol. Patient claimed that she drank water too often before being diagnosed with fluid volume overload.
Significant physical examination findings
Inspection
The patient appears ill as for the general appearance. She has swelling eyelids, hands and legs. Her skin is pallor. No rash, scars, clubbing and cyanosis. Her eyes are present with normal white sclera and normal pink conjunctiva. There is absence of any drainage from the eyes. There is a distended abdomen (distorted fluid accumulation).
Palpation
she has abnormal texture and warmth. She has no hepatosplenomegaly and masses. She presents with edema level 2+ at the extremities and normal capillary refill of less than 2 seconds. Pulses are present on both hands and legs.
Auscultation
No stenosis or murmurs heard over the 4 valves areas. She has abnormal bowel sounds
Percussion
On percussion of the posterior chest, resonance sound is heard over the lung tissues. Flat sound is heard over solid areas such as bones while dull sound is heard over dense areas such as the heart and liver.