45yr Female c/o fever and vomitings since 1 day

 45yr Female c/o fever and vomitings since 1 day.

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 patient's 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 the comment box.


Chief Complaints:

Patient complains of fever and vomiting since 1 day.


History of Present Illness:

Patient was apparently asymptomatic 4years back then developed right loin Pain and fever for which she visited Some hospital and diagnosed with Right Pyonephrosis and Right Nephrectomy was done and now she complains of fever highgrade intermittent and vomitings since 1 day.


History of Past illness:

H/o DM,BP

Not known case of CAD,CVD and Asthma


Personal History:

Diet: Mixed

Sleep: Adequate 

Appetite: Normal

Bowel and Bladder movements: Regular


Family History:

No known similar complains in the family.


General Examination:

Cyanosis: No

Pallor: No

Icterus:No

Clubbing: No

Lymphadenopathy: No

Micturition: No

Edema of feet: Yes, B/L pitting edema.


Vitals: 

Temp: Afebrile

Respiratory rate: 25bpm

Pulse: 98/min

Blood pressure: 140/90



Systemic Examination:


Cardiovascular Examination:

Thrills: No

Cardiac sounds:S1S2 positive 

Cardiac murmurs:No 


Respiratory system:

Position of trachea:Central 

Breath sounds:Vesicular 


Abdomen

Shape of abdomen: Scaphoid 

Tenderness:No 

Palpable mass: No

Henias orifices:Normal 

Free fluid: No 

Bruits: No 

 

Liver: Not Palpable 

Spleen: Not palpable 

Bowel sounds:


Central Nervous system:

 Pt is conscious, coherent, co-operatively oriented to time and place.

Speech: Normal 



Provisional Diagnosis:

Chronic kidney disease on Maintenance hemodialysis


Investigation:-












Treatment:-





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