Case history

"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 patients clinical problems with collective current based inputs.

15.4.2022.

A 30 year old female who is homemaker came to OPD with 

Pedal edema facial puffiness and SOB -3 days


HISTORY OF PRESENT ILLNESS:
patient was alparently assymptomatic three days back she developed SOB,profuse sweating generalized weakness  ,along with this pedal edema present,facial puffiness and    Diagnosed With HTN ,and now pt. came for MHD 
B/L pedal edema extending upto knees , pitting type

HISTORY OF PAST ILLNESS 

K/C/O-HTN On medication
K/C/O- CRF
Anemic 


           PERSONAL HISTORY
-The patient has No loss of appetite
-bladder movements are normal
-no sleep disturbances

FAMILY HISTORY
There are no similar complaints in the family members 

GENERAL EXAMINATION 
-Pt is conscious ,coherent ,cooperative.
-pallor
-no icterus
-no lymphadenopathy
- no cynasis
-no clubbing of fingers
-edema of feet present

VITALS
temp. 98.5'f
PR. 92 bpm
RR. 26 cpm
BP. 130/70 mm/hg
SPO2. 93%

 SYSTEMIC EXAMINATION

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea is central 

- Bilateral air entry is normal

-Normal vesicular breath sounds hear

- No added sounds

PER ABDOMEN
 -abdomen is not tender 
-no palpable mass or free fluid

CNS


- Patient is conscious

- Speech is present

- Reflexes are norm

INVESTIGATION








  

 






 




















PROVISIONAL DIAGNOSIS
-CKD on MHD

TREATMENT
-salt restriction
- fluid restriction
Tab.NICARDIA 10mg 
Tab.NODOSIS 500mg
Tab.SHELCAL CT
Tab.OROFER -XT 
Inj.EROYTHROPOETIN 4000iu
 Tab.PANTOP 40mg

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"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 patients clinical problems with collective current based inputs. 21.03.2022 A 48 year old male who is Tailor by occupation came to OPD with SOB-3 days profuse sweating since three days generalised weakness since three days  HISTORY OF PRESENT ILLNESS: patient was alparently assymptomatic three days back he developed SOB,profuse sweating generalized weakness , insidious in onset gradually progressive ,along with this pedal edema present,facial puffiness and upper limb edema and diagonsed with diabetic nephropathy with k/c/o DM type 2 and HTN ,and now pt. came for MHD  B/L pedal edema extending upto knees , pitting type HISTORY OF PAST ILLNESS K/C/O-HTN On medication            
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