A 55Yr old female with shortness of breath

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Cheif complaint:
A 55yr old female patient residence of choutupal and agricultural by occupation with cheif complaint ofshortness of breath since 1 month  and had an episode of epilepsy 2 days back.

HOPI:
Patient was asymptomatic 1 year ago then she was diagnosed with chronic kidney failure and under went hemodialysis for 6 sessions.
Patient was suffering from nausea sensation and diarrhea.she is on IV fluids since 1 week.
PERSONAL HISTORY:
Diet: mixed
Sleep: inadequate
Bowel and bladder movements: normal
No pernicious habits

GENERAL EXAMINATION:
Patient is conscious , coherent and coperative
BP :120/80MM HG
Heart rate
Pulse rate
Temperature A FEBRILE
Pallor: present
Icterus: no
Cyanosis :no
Lymphadenopathy :no
Dehydration :mild

SYSTEMIC EXAMINATION:
CVS: thrills absent, cardiac sounds s2,s3+
Respiratory system: 
Trachea position: at center
Dyspnea : no
Breath sounds : vesicular
ABDOMEN
shape :scaphoid
Tenderness :no
Palpable masses: no
Free fluid: no
Liver: not palpable
Spleen :not palpable
Bowel sounds :yes
CNS: conscious , speech normal
PROVISIONAL DIAGNOSIS : CKD
INVESTIGATIONS:
DIAGNOSIS: GRADE 3 SHORTNESS OF BREATH
TREATMENT:

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