45 years old female came to OPD complaints of loss of appetite, vomiting and itching all over the since seven days

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan

October 22,2022

Chief complaint: patient complaints of loss of appetite and vomitings and itching all over the body since seven days.
-patient was apparently asymptomatic 4 years back and developed right loin pain and fever for which she visit NIMS and she also complaints of vomitings single episode immediately after taking food.

History of present illness: 
-no fever
-no headache
-pain abdomen
-chest pain 
-no loss of appetite since seven days.

History of past Illness: 
-n/k/c/o- htn,DM,asthma,and cad

Treatment history:
-no diabetes
-no htn
-no cad
-no asthma
-no TB
-no known history of taking antibiotics and chemo therapy, radiotherapy,blood transfusion
Surgeries undergone: right nephrectomy.

Personal history
-married
-occupation: farmer
-appetite: lost
-mixed diet
-bowel and bladder: regular
-micturition: normal
- no known allergies
-no addictione
Family history :
No other family member had similar complaints
Menstrual history:
Age of menarche: 13 years
Menstrual cycle: 30/3
-no any other gynaecological problems
Physical examination: 
-no pallor
-no cyanosis
-no icterus
-no lymphadenopathy
-no clubbing of fingers and toes
-no pedal edema
-no malnutrition
-no dehydration
Vitals:
Temperature: afebrile
Pulse rate: 84bpm
Respiratory rate:16cycles/min
BP: 120/80mmhg

Systemic examination: 
-Cvs: no thrills and cardiac murmurs
-Cardiac sounds- s1,s2 positive
-Respiratory system: no dyspnea,no -wheeze.
-Position of trachea- central
-Breath sounds: vesicular 
-abdomen- shape of the abdomen scaphoid, no tenderness,no palpable mass, hernial orifice normal, no free fluid
-liver and spleen - not palpable
-bowel sounds- present
--Cns: level of consciousness- conscious
-speech: normal
-signs of meningitis: no neck stiffness
                                     no kernigs sign
Provisional diagnosis: nephropathy
Investigations;



Treatment:
Tablets: lasix 40mg
                Nodosis
                 Shelcal
                 Orofer
Inj: iron 200mg iv(every alternate day)

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