Elog on Renal failure

            This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.

                   This E blog also reflect my patient centered online learning portfolia and your valuable inputs on the comment box is welcome.

                 

                 I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan....

•55 yr old female patient came to opd on 28/9/21 with chief complaints of shortness of breath(SOB) on exertion,Pedal edema,Facial puffiness.Treated conservatively and got discharged on 4/9/21 after going home.

H/O present illness:-

*Patient gain developed SOB doing regular activities like walking 

•urine output decreased 

•No Orthopnea

•No h/o fever,vomiting,loose stool,pain in abdomen,chest pain.

H/o past illness:-

•DM type 2 since 15 yrs

•HTN since 10 yrs

Family history:-

•No family history.

Diet:-

•Normal appetite 

•Predominantly non veg

•Sleep adequate 

•Bladder regular

•Bowel regular

General examination:-

Patient is conscious and coherent.

No pallor

No icterus

No cyanosis

No clubbing 

No lymphadenopathy 

No edema of feet

No malnutrition 

No dehydration 

Vitals:-

Temp:98.4 F

Pulse:84bpm

Resp.rate:24/min

Bp:120/80 mm Hg

Systemic examination:-

•CVS:-

  S1 S2 heard no murmurs

•Respiratory system:-

Dyspnea 

Vesicular breathing sounds 

No wheezing

•Abdomen:-

Scaphoid,bowel sounds heard

•CNS:-

 Conscious and normal speech,

 Normal gait,

 Cranial nerves normal,

 Sensory system normal,

 Motor system normal.

•Investigations Ordered:-

•Blood investigation:

•Urine examination:

•RFT:

•LFT:

•Ecg:-

Provision diagnosis:-

•UTI.

•Renal failure secondary to nephrotic syndrome.

•IDA.

•Cardio renal type 5.