A 40YR OLD FEMALE WITH VOMITING AND NAUSEA.
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
CHEIF COMPLAINT:
PT aged 40 yrs F Farmer by occupation came to opd with c/o of Vomitings since 15 days nausea since 15 days
HISTORY OF PRESENT ILLNESS:
Pt was apparently normal 4yrs back then she had burning micturition pedal edema and rt loin pain and diagnosed with renal calculi(2 to 3 cm)
Pt has right kidney nephrectomy in 2018
Since 10 to 15 days pt had nausea and Vomiting 
HISTORY OF PAST ILLNESS
Right kidney nephrectomy in 2018
N/k/c/o hypertension, diabetes mellitus,asthama, epilepsy 
PERSONAL HISTORY 
Mixed diet
Married
Normal appetite
Burning micturition
NO Known addictions
PHYSICAL EXAMINATION 
Patient is conscious, coherent and cooperative
•Moderately built and Moderately nourished
•No signs of - Pallor
                       Cyanosis
                       Clubbing
                       Icterus
VITALS
•Temp - 98.4F
•Pulse rate - 82BPM
•RP - 16/min
•BP - 130/70 mm hg
•SPO2 - 98
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
•S1, S2 heard
•No murmurs
RESPIRATORY SYSTEM:
•Position of trachea - central
•Breath sounds - vesicular
ABDOMEN
•Shape - scaphoid
•No Tenderness
•No palpable mass
•No free fluid
•Spleen and liver not palpable
CENTRAL NERVOUS SYSTEM:
•Intact
•No focal defect
•No abnormality detected.
INVESTIGATIONS 
BLOOD TEST:
Creatinine:-6.0 gm/dl
Urea:113 gm/dl
Ultrasound
DIAGNOSIS
ACUTE RENAL FAILURE.
Comments
Post a Comment