40 yr female pt with fever and pedal oedema

40 yr female with fever and pedal oedema

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 inputs. This E-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


40 yr female who is farmer by occupation resident of Masanepelli village,Janagam mandal ,Yadadri district 
came with chief complaints of
- Fever since 1 week,subsided 3 days ago
- Pedal oedema since 1 week
-Facial puffiness since 1 week
-Burning micturition 1 week ago ,subsided 3 days ago
-Head ache,neck pain - 1 day
HOPI:
Patient was apparently asymptomatic 1 week ago then she developed fever  which was for 3 days which is high grade , intermittent, relieved on medication.Then she developed pedal oedema 3 days ago extending upto knee,pitting type 
Past history:
Denovo HTN
N/K/C/O DM, Asthma, TB, Epilepsy, CVA, CAD
Present history:
Appetite -Nornal
Diet-Mixed
Bowel and bladder habits -Burning micturition from 3 days
No Addictions
General Examination:
Patient is conscious, coherent, co-operative,well oriented to time, place and person, moderately built and nourished
No pallor, icterus, cyanosis, clubbing, pedal oedema, lymphadenopathy

Vitals:
PR:99bpm
BP:170/100
RR:25
Temp:98.4F
Systemic Examination:
CVS:S1S2 Present 
RS:BAE Present,NVBS
P/A:Soft,non tender
CNS: NAD
Investigations:

Provisional Diagnosis: Fever under evaluation with AKI
Treatment:
1)INJ.PAN 40 MG  IV/ OD
2)INJ.LASIX  IV/ BD
3)TAB.TELMA PO/ OD



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