45 year old female with loss of appetite, vomiting and itching skin

October 28, 2022

Name k. Durga bhavani
Roll no .35

This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients 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 inputs.This elog book reflect s my patients centered online portfolio and your valuable inputs on the comments is welcome.

45 years old female came to OPD complaints of loss of appetite, vomiting and itching all over the since seven days.

October 22,2022
CHIEF COMPLAINT:
 patient complaints of loss of appetite and vomitings and itching all over the body since seven days.-patient was apparently asymptomatic 4 years back and developed right loin pain and fever for which she visit NIMS and she also complaints of vomitings single episode immediately after taking food.

HISTORY OF PRESENT ILLNESS: 
-no fever-no headache-pain abdomen-chest pain -no loss of appetite since seven days.

HISTORY OF PAST ILLNESS:
 -n/k/c/o- htn,DM,asthma,and cadTreatment history:-no diabetes-no htn-no cad-no asthma-no TB-no known history of taking antibiotics and chemo therapy, radiotherapy,blood transfusionSurgeries undergone: right nephrectomy.

PERSONAL HISTORY-
married-occupation: farmer-appetite: lost-mixed diet-bowel and bladder: regular-micturition: normal- no known allergies-no addictions

FAMILY HISTORY :
No other family member had similar complaints

MENSTRUAL HISTORY:
Age of menarche: 13 yearsMenstrual cycle: 30/3-no any other gynaecological problems

PHYSICAL EXAMINATION:
 -no pallor-no cyanosis-no icterus-no lymphadenopathy-no clubbing of fingers and toes-no pedal edema-no malnutrition-no dehydration

Vitals:Temperature: afebrile
Pulse rate: 84bpm
Respiratory rate:16cycles/min
BP: 120/80mmhg

SYSTEMIC EXAMINATION: -
Cvs: no thrills and cardiac murmurs-Cardiac sounds- s1,s2 positive

Respiratory system: no dyspnea
no -wheeze.
-Position of trachea- central
-Breath sounds: vesicular

Abdomen- shape of the abdomen scaphoid,
 no tenderness,
no palpable mass, 
hernial orifice normal, 
no free fluid
-liver and spleen - not palpable
-bowel sounds- present

CNS: level of consciousness- consciouness
speech: normal
-signs of meningitis: no neck stiffness                                     no kernigs signProvisional

DIAGNOSIS: Nephropath

INVESTIGATIONS

TREATMENT

Tablets: lasix 40mg 
iron 200mg iv(every alternate day)

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