This is an online E logbook 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 a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based inputs.
CHIEF COMPLAINTS:- A 55 year old woman came to opd with
1. Bilateral swelling of legs and Shortness of breath since 10 days
2. Anuria since 10 days
HISTORY OF PRESENT ILLNESS :
The patient was asymptomatic 2 years back until she developed pain in her lower back region which radiates to the anterior groin region.
The lower back Pain Is Dull Aching type Continuous type.
She first noticed pedal oedema 1 year back which was on and off.
The Lower back ache associated with Pedal oedema aggrevated in last 10 days.
The Patient is On Maintainance Hemodialysis since 4 month.
HISTORY OF PAST ILLNESS:
The patient is was diagnosed with Hypertension 2 yrs back
No h/o epilepsy, tuberculosis.
PERSONAL HISTORY:
The patient consumes mixed diet.
There is loss of appetite,
-Has normal sleep.
-Has decreased urine output
Bowels is regular
The Patient Occasional Alcoholic and a Smoker.
FAMILY HISTORY:
There is no significant family history .
GENERAL EXAMINATION:
The patient is conscious coherent and cooperative.
-Pallor present
-No icterus
-No cyanois
-No clubbing of fingers and toes.
-No lymphadenopathy
- Bilateral pedal edema present.
VITALS:
Temperature- afebrile,
Pulse rate- 99 bpm
Respiratory rate- 22 times per minute
Blood pressure- 110/80 mm hg
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
- S1 & S2 heard
- Murmurs absent
RESPIRATORY SYSTEM:
Position of trachea - central
Normal vesicular breath sounds heard
No wheezes heard
ABDOMEN :
-Shape of abdomen- Scaphoid
-No Palpable mass
-No Free fluid present
- Liver-Not palpable
- Bowel sounds - Heard
INVESTIGATIONS :
HEMOGRAM
RENAL FUNCTION TEST
Diagnosis : CKD ON MHD
Treatment :
Comments
Post a Comment