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A 60 yr old female presented to Opd with cheifcomplaints of facial puffiness ,lower back pain and pedal edema.
History of present illness:
Patient was apparently asymptomatic 4 months back and then she noticed facial puffiness and pedal edema and also has lower back pain.
Then she was given symptomatic treatment and she also used analgesics for lower back pain. Later again she noticed the symptoms and visited local health care centre and there she diagnosed as kidney failure.
Now she was undergoing dialysis twice a week since 3 months.
History of past illness :
Patient is a known case of diabetes since 6 yrs and is on medication.
Not a known case of hypertension , epilepsy, TB and asthma.
Personal history :
Diet :Mixed
Appetite :loss of appetite since 2 days
Bladder movements : regular
Bowel movements : irregular
Sleep :inadequate since 2 days
No Addictions .
Family history:
No history of similar complaints in the family
Treatment history :
No history of allergy to known drugs.
General examination :
Patient was concious coherent and coperative well oriented to time place and person.
- pallor present
-No clubbing
-No cyanosis
-No icterus
-No generalized lymphedenopathy
-pedal edema present pitting type.
Vitals :
Temperature : Afebrile
Pulse rate: 82 beats per min
Respiratory rate : 17 cycles per min
Bp :130/ 90mm of Hg..
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
Auscultation :
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
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
Investigations :
Hemogram :
Serum electrolytes :
Serum creatinine :
Serum iron :
Blood urea :
RBS :
Serology :
Ultrasonography :
ECG :
Diagnosis : Chronic kidney disease
Treatment :
- fluid restriction < 1.5 litres per day
- salt restriction < 2 g per day
- Tab. Lasix 40 mg OD
- Tab. Nicardia 20 mg BD
- Tab. Livogen BD
- Tab. Nodosis 500 mg OD
- Tab. Bio D3 0.25 mg OD.
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