Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
Case Scenario:
65 year old female patient resident of nalgonda came to the opd with chief complaints of• shortness of breath since 1 week
• Pedal edema since 3 months
• back pain since 1 week
History of present illness:
Patient was apparently asymptomatic 4 years back then she developed flank pain, leg pain and Pedal edema bilaterally for which she consulted local practictioner and then was on medication.
Since it was not subsiding 5 months back she went to nalgonda hospital and was diagnosed with kidney failure .
Now 1 week back she came with complaints of SOB grade 2-3 ,progressive ,aggravated on walking and relieved on rest.
History of Past Illness:
K/C/O hypertension since 10 years
Not a K/C/O DM, TB, Asthma, epilepsy
Daily Routine:
She was a farmer, daily wage laborer by occupation but she stopped working since 2 years because of back pain and Pedal edema.
Wakes up at 4Am
Cooking and household activities
Breakfast at 9am
Talking to neighbours
Lunch at 12am
Sleep and wakes by 5pm
Dinner at 7pm
Sleeps by 9pm
Addictions - none
Physical Examination:
- height: not taken
- weight: not taken
- BMI: not taken
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- bilateral Pedal edema since 3 months on and off , non pitting
- no malnutrition
- no dehydration
Vitals:
On admission
TEMP-afebrile
BP-130/80mm hg
PR- 76bpm
RR- 16cpm
24/8/22
Temp afebrile
BP 130/70
PR 72 bpm
RR 16cpm
Family History:
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Systemic Examination:
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System:
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Clinical pictures:
Investigations:
Treatment:
Tab Nicardia 10mg PO BD
tab nodosis 500mg PO BD
tab shelcal 500mg PO OD
Tab orofer XT PO OD
inj erythropoietin 4000IU SC twice weekly
Inj Pantop p40mg IV BD
inj zofer 04mg IV TID
TAB zincovit PO OD
syp aristozyme 15ml PO TID 20 min before food