Final practical short case

 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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 35 yr old female patient was presented to OPD with chief complaint of shortness of breath and pedal edema past 20 days.





History of present illness:

Patient had fever 10 days back with no chills and subsided on medication

Then she developed facial puffiness and pedal edema along with decreased urinary output past 20 days.

C/o of cough with expectoration which is yellowish in color 

History of past illness:

Pt was apparently asymptomatic 2 months back then she developed chest pain for which she visited local hospital , on evaluation she was diagnosed to have chronic kidney disease and low hemoglobin, 2PRBC Transfusions were done .After PRBC transfusion she developed b/l pedal edema, which subsided on medication.

20 days back she developed b/l pedal edema, reduced urine output, sob a/w orthopnea, and PND, and facial puffiness. 

10 days back she developed fever a/w chills and rigor, which subsided on medication.

Personal history.

Htn past 3 yrs and is on medication.

No h/o of dm asthama or tb

General examination:

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - b/l present.


Vitals:

Afebrile

Bp: 170/100 mm hg

PR: 99 bpm

RR: 22 cpm

SpO2: 87% @RA

CVS: S1,S2 +

RS: BAE+


Investigation s












Tablets:

1. Head end elevation upto 30'


2. O2 supplementation if SpO2 < 90%


3. Inj. Lasix 40mg iv tid 


4. Inj. PIPTAZ 2.25gms IV BD ( D2)


5. TAB. NICARDIA 10MG PO BD 


6. TAB. NODOSIS 550MG PO BD 


7. Tab. Orofer XT PO/OD


8. TAB. SHELCAL 500 MG PO OD 


9. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,


10. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE 


11. Inj. Iron sucrose 1 amp in 100ml NS


12. SYP. ASCORYL PO TID 







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