A 50 year old with sob,pedal edema

"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"

A 50 year old female patient came to casuality with complaints of pedal edema since 3 months ,decreased urine output since 3 months ,shortness of breath since 3 days

HOPI

Patient was apparently asymptomatic 3 months back then developed fever -low grade not associated with chills

Pedal edema 3 months ago

Decreased urine output 3 months ago

Sob -progressed to grade 4i

Patient was advised for hemodialysis but pt attendees were not willing

Patient has been taking nsaids since past 20 years for her Menstrual cramps

K/C/O HTN since 2 months

GENERAL EXAMINATION -

Patient is Conscious, coherent,co operative well oriented to time,place,person

pallor-+

No icterus, No Cyanosis, No lymphadenopathy

VITALS-

Temperature -98.6F

Pulse rate- 84bpm

Blood pressure-120/90mm hg

Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PER ABDOMEN:Soft, non tender

No guarding, No rigidity

Bowel sounds present

Investigations -

Diagnosis

Chronic renal failure

Treatment

1.TAB LASIX 40mg IV/BD

2.TAB NODOSIS 500mg PO/OD

3.TAB SHELCAL PO/OD

4.TAB BIO D3 PO/OD

5.TAB OROFER XT PO/OD

Comments

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