Case history -2

 August  17, 2021

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Date of admission: 17-08-2021

A 50 year old female patient presented to OPD with chief complaint of backpain since 15 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back. She complains of stomach pain, backpain , leg pain, epigastric pain, urine urgency and burning and constipation.

No history of shortness of breath

No history of  facial paralysis.

She admitted in hospital and diagnosed it as kidney failure so dialysis was done for 4 times in 4 days.

PAST HISTORY:

2 years back she was admitted in hospital for backpain which is radiating from loin to groin. Then they  diagnosed it as kidney related problem and medication was prescribed. She was on medication for 2 years.

Recently 15 days back she had severe backpain so again she was admitted in the hospital.

No history of diabetes, CAD, asthma, TB, epilepsy, thyroid disorders.

She is a hypertensive patient since 2 years.

She had undergone uterus related surgery 20 years back.

PERSONAL HISTORY:

Appetite: low

Diet: mixed

Sleep: inadequate 

Bowel and bladder movements: regular

Micturation: normal

Addictions: no

FAMILY HISTORY:

There is no history of similar complaints in the family.

TREATMENT HISTORY:

Patient was on this  medication 

Nodosts DS 15S tablet

Cifran 500mg 

Esomefa 40DSR

Active D capsule

Lipvas 10 mg

Cilacar 10mg for 2 years.

She is not allergic to any known drugs.

GENERAL EXAMINATION:

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

There is no signs of  icterus, cyanosis,clubbing and generalised lymphadenopathy.

There is pallor and  pedal edema.

VITALS:

Temperature: afebrile

Blood pressure:140/ 70 mm Hg

Respiratory rate:20/ min

Spo2:99% at room temperature 

Pulse rate: 105 beats/ min

GRBS: 136 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing sounds

Position of trachea - central

Breath sounds- vesicular

ABDOMEN:

Shape of abdomen- scaphoid

Tenderness- no

Palpable mass- no

Hernial orifices- normal

Free fluid- no

Bruits- no

Liver- not palpable

Spleen - not palpable

Bowel sounds- yes

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious

Speech: normal

Signs of meningeal irritation- 

              neck stiffness- no

Cranial nerves - normal

Motor system- normal

Sensory system- normal

Reflexes- present

PROVISIONAL DIAGNOSIS:

Chronic kidney disease 

TREATMENT:

1 .Lasix 

2. Telmisartan

3. Calvic- D

4. Lcfer XT

5. Nifedipine 20 mg

6. Sodium bicarbonate tablets- 500 mg