GM CASE-4

  12 th October 2021


"This is online E log book to discuss our patients de- identified health data shared after taking his or her guardian's signed informed consent hear we discuss our individual patients problems through a 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 book also reflex my patient centered online learning portfolio and your valuable inputs on comment box is welcome." 

A 55 year old female patient came to casuality with chief compliant of shortness of breath, pedal edema, facial puffiness.

History of present illness : 

Patient was asymptomatic  15 days back then she developed pedal edema,shortness of breath ,facial puffiness for which she got treated. 8 days back she got discharged and developed shortness of breath while doing her  daily routine like walking, going to bathroom.

Decreased urine output since 1 day.

No fever, vomitings,loose stools, chest pain.

Past history :

Patient is a known case of diabetes mellitus since 15 years and hypertension since 10 years.

No history of asthma, tuberculosis, CAD.

Personal  history : 

Diet - mixed 

Appetite - normal 

Bowel and bladder movements- regular 

Addictions- non alcoholic &non smoker 

Family history : 

No member of the family has similar complaints.

General examination : 

Patient is conscious, coherent, cooperative and she is moderately built and nourished.

Pallor - present 

Cyanosis - absent 

Icterus - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Edema - present 

VITALS

Temperature - Afebrile 

Respiratory rate - 24/ min 

Pulse rate - 100 / min 

Blood pressure - 140/90 mm Hg 

SYSTEMIC EXAMINATION

Cardiovascular system

No thrills 

S1 ,S2 heard

No cardiac murmurs 

Respiratory system

Dyspnea - present 

No wheeze

Breath sounds - vesicular 

Abdomen 

Shape of abdomen - scaphoid 

No palpable mass 

No bruits

No tenderness

CNS 

Level of consciousness - conscious 

Speech - normal 

No neck stiffness 


INVESTIGATIONS 
HEMOGRAM


CBP
 
ECG

HIV TEST

CUR

SERUM IRON

RFT

LFT

BLOOD SUGAR
ABS

Provisional diagnosis : 

Urinary tract infection

Renal failure due to nephritic syndrome

Treatment: 

Inj PAN 

Inj Lasix 

Tab Clindipine 

Tab Arkamine 

Tab Shelcal 

Tab Orofer 

Inj Erythropoietin


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