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 Complaints:

A 60 years old female patient resident of suryapet,farmer by occupation ,complaints of back pain, stomach pain and swelling of legs since 1year


History of Present Illness:

Patient was apparently asymptomatic 1year back then she developed loin pain 

H/o pedal edema which is of pitting type

No h/o fever, burning micturition

History of Past illness:

H/o hypertension since 2months

No h/o DM,Asthma, epilepsy,CAD

Personal History:

Married

Appetite:normal

Diet:mixed

Bowel movement: regular

Micturition-normal


Family History:

No known family history

General Examination:

Vitals:

Temp: afibrile

Respiratory rate:14cycles/min

Pulse:80bpm

Blood pressure:140/80mmh

Sp O2 :97%


Systemic Examination:

Cardiovascular Examination:

Thrills:no

Cardiac sounds:S1,S2 heard

Cardiac murmurs:no


Respiratory system:

Dyspnea: no

Wheeze: no

Position of trachea: central

Breath sounds: vesicular

Adventitious sounds:no



Abdomen

Shape of abdomen: scaphoid

Tenderness:no

Palpable mass:no

Henias orifices:normal

Free fluid:no

Bruits:no

 

Liver:not palpable

Spleen:not palpable

Bowel sounds:no


Central Nervous system:

 Pt is conscious

Speech: normal

Signs of meningitis:no

Cranial nerves:normal

Motor and sensory system: normal


Provisional Daignosis:

CKD on MHD

Investigation:


Treatment:

Tab LASIX 40mg PO/OD

Tab nicardin 10mg PO/TID

Tab OROFER XT PO/OD

Tab NODOSIS 300mg PO/BD

Tab SHELCAL 500mg PO/OD





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