42 Yr old female patient elog

This is 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 best evidence based inputs. This e-log also reflects patients centered  learning portfolio. 

I have done this E log under guidance of Dr Deekshitha.

Case :

A 42 year old female patient presented with chief complaints of nausea, bilateral swellings of lower limbs and decreased urinary output. 

History of present illness :

Patient was apparently asymptomatic 20 days back, then she developed nausea, B/L swelling of lower limbs and decreased urinary output. Then went to hospital and intrude on dialysis. 

History of past illness :

K/c/o of type 2 Diabetes mellitus since 4 years, on medication
No history of HTN, CAD, asthma, tuberculosis 

Treatment history :

History of blood transfusion during dialysis. 

Personal history :

Married
Regular bowels
Normal micturition
No addictions

Family history :

No history of HTN, DM, Heart disease.

General examination :

Pallor +
No icterus, cyanosis, clubbing, lymphadenopathy
Oedma of feet +

Vitals

Temperature - afebrile
Pulse rate - 92/min
Respiratory rate - 18/min
BP- 130/100 mmHg
SPO at room air - 98%

Systemic examination 

CVS system

No thrills
Cardiac sounds are heard
No cardiac murmurs

Respiratory system

No dyspnoea 
No wheeze
Trachea is centrally positioned 
Vesicular breath sounds
No adventitious sounds 

Abdomen 

Scaphoid shape abdomen 
No tenderness, palpable mass
Normal hernial orifices
Non palpable liver, spleen
No free fluid 
Bowel sounds heard

CNS 

Conscious and alert
Normal speech 
No signs of meningeal irritation
Reflexes 
                    Right      Left
Biceps            +1         +1
Triceps           +           +
Supinator       +            +
Knee              +            + 
Ankle              +            +

Provisional diagnosis :

CHRONIC RENAL FAILURE on DIALYSIS 
K/c/o Type 2 DM since 4yrs

Investigations : 

                                  03-07-2021
RFT 


CUE

Hemogram


                             04-07-2021
RFT
Ultrasound
                                       

                                   10-07-2021 
Hemogram


                                     11-07-2021 
CUE

RFT 

ABG

                                      26-07-2021
Hemogram



                                     27-07-2021
CBP

Treatment

Fluid and salt restriction 
Inj AUGUMENTIN 1.2gm/iv/BD
Tab PANTOP 40mg/PO/OD
Tab CHYMOROL FORTE PO/TID
Tab DOLO 650MG PO/TID
Tab NICARDIA 100MG/PO/OS
Tab NODOSIS 500mg/PO/BD
Tab OROFER XT/PO/OD
Tab SHELCAL 500mg/PO/OD
Inj NEOMAL 100ml/IV/sos if temp is >101°F
Temp charting 4th hourly

END

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