E log august - 3

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

A 55 YR OLD FEMALE WITH CRF

Chief complaints :

Itching since 3 mnths
Back aches, leg aches, pedal edema since 6 mnths even after medication

Past history :

HTN since 15 yrs - is on medication

Personal history:

Lack of sleep and appetite
Mixed diet
Bowel and bladder habits normal
Toddy drinker - 1 glass/day for 30 yrs


Family history :   Nil significant

General examination :

Pallor - present

No icterus, cyanosis, clubbing, lymphadenopathy, oedema and malnutrition. 

Vitals :

Temp : 99°F
PR : 82/min
RR : 18/min
BP : 160/100 mmHg
SPO2 : 98%


Systemic examination:

CVS:

S1, S2 heard
No thrills and murmurs heard

RS:

No dyspnoea, wheeze
Trachea - central in position
Breath sounds - vesicular

P/A :

Shape of abdomen - scaphoid
No tenderness and palpable mass
No free fluid and bruise
Liver and spleen not palpable

CNS:

Conscious and coherent
Speech - normal
No signs of meningeal irritation

Provisional diagnosis:

CRF ( 2° to HTN / NSAID abuse) 


Investigations :



Treatment :

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