General medicine e-log

 Name : P Nikitha

 Roll no: 102

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 portfolio and your valuable inputs on the comment box. 


A 42 year old female,sweeper by occupation came to the casualty with...... 

CHIEF COMPLAINTS OF Fever, vomitings, shortness of breath, oedema since 1 week. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 yr back, then she developed severe back pain and she used pain killers and relieved pain temporarily and after 2months she again developed back pain, vomitings, shortness of breath and fever.

She visited local hospital their doctors reffered to visit KIMS narketpally.

HISTORY OF PAST ILLNESS:

She was underwent with some nasal surgery 15months back in a local hospital, she was asymptomatic for next 3 months. 

Known case of
  • CKD on MHD since 1 year
  • Hypertension since 1 1/2 yr and on regular medication. 

FAMILY HISTORY:

not significant

TREATMENT HISTORY OF PAST:

Inj LASIX - 40mg IV/BDT

NODOSIS 550 mg PO/BDT

SHELCAL 500 mg PO/BDT

OROFER XT PO/ODT

NICARDIA 20 mg PO/BDSALT 

Fluid restriction 

GENERAL EXAMINATION:

 -The patient is conscious, coherent,cooperative and well oriented to place and time. 

-Edema of feet present, pitting type upto the knee, edema of face and hands are also seen. 

-Absence of Cyanosis, Pallor, Icterus, Lymphadenopathy, clubbing.

-facial puffiness and oliguria are present. 

VITALS:

Temperature: febrile

PR:-80

RR :- 27 cpm

BP:- 190/110


CVS EXAMINATION :

S1, S2 heard 

No Murmurs or thrills


RESPIRATORY SYSTEM EXAMINATION :

Dyspnoea - present 

Wheeze - Absent 


CNS EXAMINATION:

All superficial and deep reflexes are normal. 


INVESTIGATIONS:

            DIALYSIS REPORT: 














DIAGNOSIS:

CHRONIC KIDNEY DISEASE

TREATMENT:

Dialysis




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