A 50 years old female c/o fever, vomiting, burning micturition,SOB
A 50yrs old female c/o fever, vomiting, burning micturition,SOB
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 box.
Chief Complaints:
C/O Fever since 10days, Burning micturition since 10days, vomitings since 10days (5-6 episodes),Grade 3 SOB since 10days
History of Present Illness:
Patient is apparently asymptomatic 10days back then she noticed fever low grade,continuous type not associated with chills and rigors
H/o vomiting non projectile,non bilious,food as content
C/o SOB Grade 3 since 3days
C/o burning micturition after foleys insertion at local hospital
History of Past illness:
H/o hypertension since 2months (on regular medication)
No h/o DM,Asthma, epilepsy,TB,CAD
Personal History:
Married
Occupation: daily wage labour
Diet:mixed
Appetite:normal
Bowel movements: regular
No drug allergy
Family History:
No h/o DM, Asthma, Hypertension,TB,CAD, Epilepsy in the family
Menstrual history:
Menopause:20years back
General Examination:
Vitals:
Temp: Afibrile
Respiratory rate:24bpm
Pulse:86bpm
Blood pressure:130/90mmhg
Sp O2:96
Systemic Examination:
Cardiovascular Examination:
Thrills:No
Cardiac sounds:S1,S2 sounds
Cardiac murmurs:No
Respiratory system:
Position of trachea:central
Breath sounds: vesicular
Adventitious sounds:no
Wheeze:no
Dysponea:no
Abdomen
Shape of abdomen: scaphoid
Tenderness:not tender
Palpable mass:no
Henias orifices: normal
Free fluid:no
Bruits:yes
Liver:not palpable
Spleen:not palpable
Bowel sounds:yes
Central Nervous system:
Pt is conscious
Speech: normal
Signs of meningitis:no
Cranial nerves: normal
Motor and sensory system:normal
Provisional Diagnosis:
CRF
Investigation:
Treatment:
Tab.NICARDIA 10mg PO BD
Tab.NODOSIS 50Pmg PO BD
Tab.LASIX 40mg PO BD
Tab.OROFEX XT PO OD
Tab.SHELCAL PO OD
Inj.ERYTHROPOITEIN IV Weekly once
