Case history

 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 patients 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 comment box is welcome .

A 60 yr old female .patient presented to OPD with cheif complaint of pain in the lower back region (right side) since 2 years and shortness of breath since 1 year 

HISTORY OF PRESENT ILLNESS 

patient was apperently a symptomatic when she noticed the pain in the lower back region 

Pain gradually increased during the time and it is more while walking 

Patient is undergoing dyalsis since 2 months weekly twice 

History of  SOB since a year

Patient complains of body pains  

PAST HISTORY : 

Patient had a accidental thorn pric in the left eye and asymptomatic for 3 months later she noticed the discharage of pus from the eye  

Consulted to doctor and suggested for removal of eye  

Patient is in frequent use of eye drops since 6 yrs

Patient developed pedal edema  2 months back and consulted a doctor .

History of hyper tension since 1 yr 

No history of DM  epilepsy etc..

PERSONAL HISTORY : 

Married . 

DIET : mixed 

Appatite: normal

Sleep : adequate 

Bowl and bladder : normal 

No history of any addictions 

FAMILY HISTORY : 

 No similar complaint in the family 

TREATMENT HISTORY : 

patient was on medication before eye surgery 

Patient used pain killers for 6 yrs 

No history of allergy to known drugs 

GENERAL EXAMINATION : 

patient was well built concious coherent and well norushied 

No pallor 

No icterus

No cynosis 

Bypedal edema is present 

No lymph node enlargement 

Vitals : 

Temp : 98.6 ⁰F 

Pulse : 88 beats / min 

BP : 140/90mm hg 

Resp rate : 16 cycles / min 

SYSTEMIC EXAMINATION : 

CVS : s1 and s2 are heard 

          No cardiac murmures heard

CNS : consicious

         Speech . Normal 

Respiratory system : no wheezing 

            position of trachea: central 

Per abdomen : liver not palpable ,

                      spleen not palpable

                    ,no palpable mass in abdomen 

                     , no bowel sounds. 


INVESTIGATIONS : 

CBP :


Blood urea : 


Serum creatinin : 


Serum electrolytes: 


Complete urine examination : 



DIAGNOSIS : 

chronic kidney disease 

TREATMENT : 

dyalsis 

Tab.Augmintin 60mg 

-Tab.Dolo 650mg 

-Tab.Asprini 7mg 

-Tab.Pan 40mg 



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