22 YRS OLD FEMALE WITH GENERALISED SWELLING OF BOSY AND REDUCED URINE OUTPUT

 Hi, I A satyanarayana 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

                A female patient of 22 yrs in old from Raolpet came to casuality with complaints of Generalised swelling of body and and reduced urine output since 5 to 6 days.

CHIEF COMPLAINTS AND DURATION: 

Generalised swelling of body and reduced urine output from 5 to 6 days 

HISTORY OF PRESENT ILLNESS:

Patient was apparently alright 6 days back then she developed generalised swelling of body and low urine output 

HISTORY OF PAST ILLNESS:

The patient is known case of diabetes since 15 years and Hypertension since 2yrs 

PERSONAL HISTORY:

Diet: mixed

Appetite:lost

Bowels :Regular

Sleep: normal

No allergies

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative

No cyanosis

No icterus

Pedal edema present

No lymphadenopathy

No clubbing of fingers 

Patient is unconscious

Vital signs

Temp:99f

Pulse rate:120/min

BP:140/90

Spo2:96%

Systemic examination 

Cardiovascular system:

s1,s2 heart sounds heard

No additional sounds heard 

Respiratory system:

Trachea central in position

Normal breathe sounds heard

Gastrointestinal system 

No tenderness over any region

No palpable mass in abdomen region

Central nervous sysytem

Patient is conscious 

Speech:normal

All reflexes are present

Lab diagnosis

Provisional diagnosis

CKD on MHD

Diabetic nephropathy

TREATMENT HISTORY:

Injection piptaz 2.25 gm/IV

Injection pan 40 mg / IV 

Injection Zofer 4 mg /IV 

Injection Lasix Iv 

Tav Nicardia 20 mg 

Tab Telma 20 mg

Tab orofer xj 

Tab nodosis 500 mg

Tab shelcal 500 mg