General medicine case-2

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

Chief complaint: 

A 60 year old female who is daily labour by occupation came to the OPD with the chief complaint of pedal oedema and fever 

History of present illness:-

Normal routine of the patient

The patient wakes up by 5am daily in order to complete her work.

The patient was apparently asymptomatic 6 months back the she experienced fever ans swelling of legs

 she was diagnosed with hypertension.

She started taking medicines prescribed by the local doctor & after few days she experienced backache.

The local doctor suspected renal problem and was checked for the serum creatinine levels  Which were very high.

She was continuing  medicines for renal problems as well .

She then came to OPD with these complaints and was diagnosed with chronic kidney disease.


PERSONAL HISTORY:

 TAKES MIXED DIET, MARRIED.


ADDICTIONS REGULAR ALCOHOLIC 

APPETITE: NORMAL


BOWEL AND BLADDER, REGULAR

 NO KNOWN ALLERGIES.

PALLOR

NO ICTERUS CYANOSIS CLUBBING.LYMPHADENOPATH


OEDEMA OF FEET


VITALS


AFEBRILE TEMPERATURE

PR:848


BP: 140/90MM


RR: 22C


SPO2 94% AT ROOM TEMPERATURE


SYSTEMIC EXAMINATION


RESP SYS: BA


CNS 

PER ABDOMEN: SOFT,NON TENDER


Investigation

NO SIGNS OF MALNUTRITION AND DEHYDRATION





















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