General medicine case discussion

B.Varshitha 
5th semester 
Roll no.21
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

A 13year old female patient came to the hospital with cheif complaints of swelling of both lower limbs and face since 15days

History of present illness 
Patient was apparently asymptomatic 2months back then she got 2 episodes of vomitings for 1days which is not associated with abdominal pain
15 days back after a journey for 3hours she developed swelling of limbs and face and swelling of limbs progressed  for the next 7days and then they went to a local hospital where she got medication and pain got subsided and 3days back she was admitted here 
Swelling initially till ankle now progressed to generalized edema with facial puffiness
No H/O burning micturation and decreased urine output
No H/O fever 
No H/O shortness of breath 
No H/O weakness

History of past illness 

N/k/C/O HTN diabetes epilepsy TB asthma 


Personal history 
• Diet : mixed
• Appetite: normal 
• Sleep : adequate 
• Bowel habits: normal 
• Bladder habits : normal 
• No Addictions 


Family History 
H/O diabetes is present for the patient's mother since 3 years
H/O Epilepsy is present for the patient's father 
H/O CKD

Physical examination 

General examination 
• No pallor
• No icterus
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished.
Pedal edema on both the lower limbs 
Vitals
Temperature: Afebrile 
Pulse rate: 88/min
BP:110/70 mm/Hg
RR:16/min


SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

No Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN
No Distended abdomen 
No tenderness 
No palpable mass
No free fluid 
No briuts
No palpable spleen and liver


CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness
Sensory system- Normal
Motor system- normal

Provisional diagnosis: anasarca secondary to nephrotic syndrome

Investigation 


Treatment 
27/06/22
TAB AMOXICLAV 625MG PER ORAL THRICE DAILY 
TAB LASIX 20MG PER ORAL TWICE DAILY 
SALT RESTRICTED DIET 
BP PR AND TEMPERATURE MONITORING 4TH HOURLY 

28/06/22

TAB AMOXICLAV 625MG PER ORAL THRICE DAILY 
TAB LASIX 20MG PER ORAL TWICE DAILY 
SALT RESTRICTED DIET 
BP PR AND TEMPERATURE MONITORING 4TH HOURLY 

29/06/22

TAB AMOXICLAV 625MG PER ORAL THRICE DAILY 
TAB LASIX 20MG PER ORAL TWICE DAILY 
SALT RESTRICTED DIET 
BP PR AND TEMPERATURE MONITORING 4TH HOURLY 


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