50 yr old female with decreased urine output

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Date of examination: 20-7-2021

A 50 yr old female presented to Opd with cheifcomplaints of decreased urine output and swelling in the legs and facial puffiness since 20 days.

History of present illness:

*Patient was apparently asymptomatic 1month ago then she had intermittent fever and then visited medical care centre and diagnosed as ovarian cyst then she was reffered for hysterectomy.

*During hysterectomy she was diagnosed as kidney malfunctioning.

*Then she was apparently asymptomatic for a week and then she noticed pedal and facial edema and decreased urine output &shortness of breath and then reffered for dialysis.

*She associted with fever and vomitings after dialysis.

*Patient complaints of altered sleep cycle

History of past illness:

*Has history of TB 20 yrs ago used medication for 6 months and then diagnosed as normal.

*Has history of blood transfusion one month ago.

*Not a known case of hypertension , diabetes,CAD,asthma, epilepsy and thyroid disorder.

*History of hysterectomy one month ago

Personal history:

Diet: Mixed

Apetite:normal

Sleep:altered sleep cycle

Bowel:regular

Micturation:no urine output

Addictions:No

Menarche: 12 yrs

Normal menstrual cycle with Normal flow

She is married and has 4 children.

Family history:

History of TB in family (husband&father)

Treatment history:

She is treated priorly with IV antibiotics, IV antacids, IV analgesics, IV antipyretics, IV multivitamins, renal protective agents and other supportive care medications.

*No history of drug allergy.

General examination:

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

*There is bilateral pedal edema (pitting type) and pallor

*No history of cyanosis, clubbing,lymphadenopathy.

Vitals:

Temperature:101°F

Pulse rate: 80 /min.

Sp02:98%

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