Case history no 1

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Date of admission:- 20/7/2021

    A 50yr old female presented to OPD with chief complaints of decreased urine output, swelling in the legs and facial puffiness since 20 days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 1 month ago then she had intermittent fever and then visited a medical care centre where she was diagnosed with Ovarian cyst,  then she was referred for hysterectomy 

*During hysterectomy she was diagnosed as kidney malfunction.

*Then she was apparently asymptomatic for a a week then she  noticed pedal and facial edema ,decreased urine output, shortness of breathe and then referred for dialysis.

*She is associated with fever and vomitings after dialysis.

*She also complaints of altered sleep cycle and loss of appetite since a week 

HISTORY OF PAST ILLNESS:-

*Has history of TB 20 Yrs ago, she was on medication for 6 months and then she was diagnosed as normal.

*Has history of blood transfusion one month ago.

*Not a known case of Hypertension, Diabetes, CAD,asthama,epilepsy and thyroid disorder 

She has history of hysterectomy 1 month ago.

PERSONAL HISTORY:-

Diet:-Mixed

Appetite:-Normal

Sleep:-Altered sleep cycle 

Bowel:-Regular

Micturation:-No urine output 

Addictions:-No

Menarche:-12yrs

Normal menstrual cycle with normal flow

She is married and has 4 children.

FAMILY HISTORY:-

Has a history of TB In family (Husband and Father)

TREATMENT HISTORY:-

She was treated priorly with IV Antibiotics, IV Antacids,IV Analgesics,IV Antipyretics ,IV Multi vitamins , Renal protective agents and other supportive care medication.

No history of past drug allergy.

GENERAL EXAMINATION:-

Patient is conscious,coherent and cooperative well oriented to time place and person.

Their is bilateral pedal edema(Pitting type) and palor.

No H/O Cyanosis

 No H/O  Clubbing

No H/O Lymphadenopathy.

VITALS:-

TEMPERATURE:-101°F

PULSERATE:-80bpm

BLOOD PRESSURE:-120/80mm of hg

SpO2:-98%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

INVESTGATION:

Pedal edema:

ECG:

Haemogram:

Serum creatinine:

On 30-7-2021

RFT:

On :1-8-2021

On 2-8-2021

ABG:

Blood urea:

Serum electrolytes:

Final diagnosis:

Chronic kidney disease

Treatment:

Tab lasix 40mg PO/BD

Tab orofer XT PO/BD.