GENERAL MEDICINE E-log

NAME: A Sanvith

ROLL NO: 09 

Date: 09/06/2022

INTRODUCTION

A 30year old female, housewife by occupation came to casuality.

CHIEF COMPLAINTS

Abdominal distenstion 9days back

Abdominal pain 

Fever 12 days back

Pedal oedema since 9 days.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 12days back and had sudden onset of fever, Onset of swelling in the b/l lower limbs gradually progressive below the knee which is pitting type and no tender associated with abdominal distention.

Decreased urine output and shortness of breath at rest.

History of nausea, vomiting before admitting the hospital.

HISTORY OF PAST ILLNESS

Not a known case of asthma, TB, epilepsy, diabetes 

K/c/o HTN since 6 years 

PERSONAL HISTORY 

Mixed diet

Liss of appetite 

Bowel movements regular 

Sleep adequate 

No known allergies 

FAMILY HISTORY 

Not significant 

GENERAL EXAMINATION 

Pallor present

No icterus 

No cyanosis

No lymphadenopathy 

B/L pedal oedema is present

VITALS 

TEMP: 98.7

BP: 126/60 mm of hg

SPO2 : 98%

PR: 120BPM

SYSTEMATIC EXAMINATION

CVS

S1,S2 heard

RESPIRATORY SYSTEM

BAE +

ABDOMEN

No palpable mass

No tenderness

No bruits

Liver not palpable

Bowel sounds yes

CNS

Consious and coherent 

Normal speech

No neck stiffness

Motor and sensory system normal

INVESTIGATIONS

10/06/2022




12/06/2022




13/06/2022




15/06/2022






17/06/2022




PROVISIONAL DIAGNOSIS 

Chronic kidney disease






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