General medicine elog 2

14- 06-2022
   
Hi ,I am Swetha ,3 rd semester student .This is an online elogbook to discuss our patient health data after taking her consent.This also reflect my patient centered online learning portfolio.
Cheif complaint: A 64 year old female housewife by occupation resident of Nalgonda district ,came with complaints of backpain, burning micturition,edema ,low urine output, shortness of breath .
HOPI: the patient used to have backpain ,used medication but ,it increased from past 10 days , oliguria , burning micturition from 10 days , shortness of breath. No history of daibetes, vomiting.no covid vaccination.
Past history: 4 yrs ago hysterectomy was done 
Personal history : bowel regular , non-vegetarian diet,no known allergies,no history of any drugs tabacco pan alcohol 
Family history:no diabetes ,heart disease, stroke , hypertension,TB, asthma 
General examination:
No pallor icterus clubbing of fingers lymphadenopathy 
Temp:98.6
PR :98/min
RR: 18/min
BP: 110/80
Spo2: 98%
GRBS:112mg%
Systemic examination:
CVS : cardiac sounds present
Respiratory system: no dyspnea, wheeze, position of trachea central
Abdomen: scaphoid shape ,no tenderness,no palpable mass
CNS : conscious, coherent, cooperative , normal speech .
diagnosis : CKD on dailyasis ( 2 times in a week)
treatment

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