A 45 yr old female patient complains of loss of appetite burning micturation and inadequate sleep

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.
CHIEF COMPLAINT:
A 45 yr old female patient  came to the causality with a complaint of loss of appetite , burning micturation  and inadequate  sleep since 2months
HISTORY OF PRESENT ILLNESS:  A 45 yr old female patient who agricultural  labour 
by occupation  was apparently asymptomatic since two months then she noticed loss of appetite burning micturation and inadequate sleep 
Firstly she visited near by local hospital  
HISTORY OF PAST ILLNESS:
4yrs back she had undergone( right kidney )
Nephrectomy
Blood transfusion (6 packets) 3months back
No h/o hypertension, diabetes, epilepsy, 
Asthma, thyroid 
PERSONAL HISTORY: 
married
Diet : mixed
Appetite: decreased 
At present normal
Sleep : inadequate 
Micturation  : burning 
At present  normal micturation
Bowel and bladder movements  : regular
Menstrual history : irregular
No addictions 
No drug allergy  to known drugs 
FAMILY  HISTORY  :
No relevant family  history 
GENERAL  EXAMINATION  :
 Patient is conscious coherent cooperative and well oriented to time place and person 
H/o pallor unilateral pitting  type of pedal edema  facial puffiness 
No cyanosis clubbing 
Vitals :
Temp : afebrile 
BP: 110/ 80
RR : 18 
PR : 71
SYSTEMIC  EXAMINATION  : 
CVS : no thrills no cardiac murmurs 
S1s2sounds heard
RS :no wheeze no dysponea
Position  of trachea  : central
Abdomen 
On inspection 
Shape : distended 
Scars present 
Symmetrical  movements  of abdomen
Umbilicus : inverted
No dilated veins
On palpation
Superficial palpation  : no tenderness  
Warmth body
Deep palpation
Liver : palpable
No tenderness  
Lower border is palpable unable to locate upper border
Spleen : palpable
No tenderness 
On percussion  : 
No fluid thrill
No shifting  dullness
Liver : dull note
Spleen : dull note
Auscultation:
Bowel sounds :10 /min
CNS : conscious 
No neck stiffness 
Normal  speech
PROVISIONAL  DIAGNOSIS: chronic kidney disease 


INVESTIGATIONS :
ECG
ultrasound 
Hemogram :

Serum iron : 55 
TREATMENT  :
On dialysis  since 2months

Comments

Post a Comment

Popular posts from this blog

A 60 year old male came with chief complaint of fever and Head ache

Image
This is an oneline e-blog depicting patient's de-identified data centred  approach for learning medicine. This log has been created after taking concert from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them  Chief complaint : A 60 year old male patient came to casualty with a complaint of fever with chills and head ache since 1 week  History of present illness  : A 60 year old male patient who was farmer by occupation was apparently asymptomatic 1 week back then he notice fever with chills and headache, relieved on taking medication and he visited other hospital before coming here they gave a report positive for widal test  Uncontrolled diabetes (2 days) History of past illness : History of diabetes (on medication since 18 years) No history of hypertension, asthma,TB,Epilepsy, Thyroid Personal History : Married Diet : vegetarian  Appetite  : Normal Sleep : Adequate  Allergies : No Bowel movements  : Regular  Mict
Read more

A 45 years old male patient with pedal edema

Image
This is oneline e-blog to discuss our patient De-identified health data shared after taking his 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 patients clinical problems with collective current best evidence based inputs  Chief complaints      A 45 year old male came to casualty with a complaint of pedal edema and SOB History of present illness        A 45 year old patient who is security by occupation was apparently asymptomatic one week back then he developed pedal edema with Decreased urine output and SOB gradually progressed increased on exertion      First he went to private hospital and undergone dialysis four times History of past illness      He was diagnosed with HTN for which he ordered renal function tests 3 years ago where his renal parameters has been damaged. He was Conservative treatment for about 3 years  N/k/c/o Dm,Asthma,
Read more