Hi, I am soumya 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.


CASE SHEET:

Chief complaints:
 22 year female came to causality with facial puffiness, decreased urine output,low back ache since 5 months

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 5 months back. She then developed facial puffiness followed by fever , chills, pedal edema , decreased urine output 


PAST HISTORY

No past history

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: Decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

GENERAL EXAMINATION:

pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema

VITALS:

Temperature: 98.5 F

Pulse: 86 beats per minute

Respiratory rate: 20 cycles per minute

Blood pressure: 110/90 mm of Hg

SPO2: 98%

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