Skip to main content

65 YR OLD FEMALE WITH SOB

This is 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 patients’ clinical problems with collective current best evidence-based inputs. 


A 65 yr old female Home maker by occupation resident of Vangamarthi was presented to the OPD with chief complaints of :

Pedal oedema since 10 days 

decreased urine output since one week

On and off fever since one week

Shortness of breath since two days

HISTORY OF PRESENTING ILLNESS

the patient was apparently asymptomatic four years ago when she developed prolapsed uterus  for which she underwent hysterectomy And then she developed high grade fever. She was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.

 She has been taking NSA IDs for joint pain since four years

The patient complains of shortness of breath which is of grade 2

History of past illness:

 The patient was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.

No history of hypertension

No history of DM

No history of thyroid 

Personal history

Appetite normal

Diet mixed

Bowl and ladder moments regular

No known allergies

Consumes alcohol occasionally

No history of smoking


Family history

No significant family history


Examination

General examination

Patient is conscious coherent and cooperative

Patient moderately built and nourished

No pallor

No cyanosis

No lymphadenopathy

No icterus

No clubbing

Vitals

Temperature 98.6° F

PR 98bpm

RR 18 per minute

BP 110/80 mmHg

Systemic examination 

CVS

S1 S2 heard 

No murmurs

RESPIRATORY SYSTEM 

Position of trachea central

BAE +

No audible wheeze

Abdomen 

Soft, non-tender

Liver spleen not palpable

INVESTIGATIONS 















USG FINDINGS:
1.)E/O 6-7 mm calculus noted in contracted gall bladder

2.) E/O 24*21mm cystic leisons noted in lower pole of Rt kidney

3.) E/O multiple cysts noted in Lt kidney 

Impression:

1.) grade 1 in RT kidney and grade 2 in lt kidney changes with BL renal cortical cysts
2.) cholelithiasis

PROVISIONAL DIAGNOSIS:

Chronic renal failure

TREATMENT:

DATE: 7/6/2022

Tab Lasix 40mg /PO/BD

Tab nodosis 500mg /Po/BD

Inj epo 5000 IU/SC /once weekly

Inj iron sucrose 1 AMP in 100ml NS /OD

Tab shelcal 500mg /PO/OD

Tab orofer xt /PO / OD


DATE: 8/6/2022


Tab Lasix 40mg /PO/BD

Tab nodosis 500mg /Po/BD

Inj epo 5000 IU/SC /once weekly

Inj iron sucrose 1 AMP in 100ml NS /OD

Tab shelcal 500mg /PO/OD

Tab orofer xt /PO / OD

Tab pan 40mg/PO/BD






Comments

Post a Comment

Popular posts from this blog

A 65 yr old female with ascites

This is 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 patients’ clinical problems with collective current best evidence-based inputs.   A 65 year old female, resident of suryapet , who used to be a farmer by occupation was presented to the opd with chief complaints of CHIEF COMPLAINTS: Fever since 15 days SOB since 15 days Decreased urine output since 15 days HISTORY OF PRESENTING ILLNESS the patient was apparently asymptomatic 20 days ago when she developed fever and decreased urine output for whivh she visited a local hospital and was on medication. The fever subsided.4 days later her urine output decreased and gradually developed abdominal distension over a period of 5 days. For this she went to a hospital where she was told that she has a...
Post a Comment
Read more

13 Medha Baswa

  I am, B.Medha, MBBS 3rd semester roll no: 13 I have been given this   assignment  that I shall evaluate the examinees aptitude for  a) scholarship, which is reflected in their ability to read comprehend, analyze, reflect upon and discuss captured patient centered data as in their 'original' answers to the assignment for May 2021.  b) scholarship of integration, which is reflected in  1) their ability to connect with and capture patient centered data (as already demonstrated by many of the 2019, 2017, 2016 batch students who have captured it in their E logs as a part of their formative assessment)  2) their ability to connect with and engage in shared learning with their peers through peer review feedback.    QUESTION 1 1 NEUROLOGY roll no 8 , answer no:  1 https://08arshewarpavankumar.blogspot.com/2021/05/a-40-year-old-male-with-complaints-of.html evolution of symptomology well explained. it was well comprehensable, easy to understand....
Post a Comment
Read more

60 year old female with convulsions

  The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.  Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-log also reflects my patient's centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom. A 60 year old female, resident of Nalgonda district, farmer by occupation, presented with  CHIEF COMPLAINTS: Involuntary movements and loss of consciousness  HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 20 years ago, when she...
Post a Comment
Read more