MEDICAL ELOG

MEDICAL LOG BOOK BY N. LAVANYA
ROLL NUMMBER - 93  

                        3 RD SEMESTER  STUDENT 


A 57 year old female from siri konda came to opd with 

cheif complaints of 

Shortness of breath since 7 days 

Cough with yellowish colour sputum since 7 days 

Fever with no assossiated chills and rigour since a week 

And  decreased urine out put since 3 days 


History of presenting illness 

Patient developed  generalized oedema  3 days back 

which are slow in onset and initially started at the legs

 and  developed all over the body .

Patient was asymptomatic previously : 

3 years back she developed  low back pain radiating 

to right groin diagnosed with Renal caliculi    got 

treated 


Past History 

No  History of Diabetes , Hypertension 

Asthama ,epilepsy ,  Tuberculosis and COPD 


Personal history 

Diet : Mixed 

Appetite : decreased 

Sleep: adequate 

Bowel movemnts  : Normal

Micturation : Decreased urine out put 

                         No assosiated  pain 

  No Addictions 

Fever chart 




Family History

Not significant 

General examination 

The patient is conscious , coherent ,well oriented to 

place and time . 






Pallor 

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy 

 Bi lateral Odema of legs  ( pitting type) 


Vitals 

Temp : 98.5

Bp: 100/60

RR : 22

PR : 98.6

Spo2 : 87

Systemic Examination 

CVS 

S1  and s2 heard 

No thrills 

No cardiac murmurs 

Respiratory system 

Presence of dyspnoea and wheeze 

Position of trachea _ central 

Vesicular breath sounds 


Abdomen 

No tenderness  , palpable mass, free fluid 

CNs 

Conscious , Normal speech 

Provisional Diagnosis

CRONIC KIDNEY DISEASE 

Investigations 

0N 16 /12/21 

Pleural effusion was Done 

Report : Acute inflammatory  Smear 



RENAL FUNTION TEST






ULTRA SOUND REPORT 


  2D ECHO REPORT 


ME




TREATMENT

 Tab  Azithromycin 500 mg

Inj lasix 40mg / IV

 tab nodosis 550 mg

Inj erythropoietin 4000 IU ( weekly once )

Inj iron sucrose 1 amp in 100 ml

 syrup ascoril 

tab orofer


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