long case: 65 yr old female patient With CKD
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Chief complaint:
A 65 years old female with chief complaint of :
* pedal edema since - 3months.
* Shortness of breath since - 3 months
* Decreased urine output since 3 months.
History of present illness:
Patient was apparently asymptomatic 1yr back then she noticed decreased urine output and then diagnosed heart failure and renal failure and started Medication.
Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles
shortness of breath - grade 3 insidious onset and progressive and which is subsided now.
No history of Burning micturition,PND,Cough,Cold,Fever
History of past illness:
K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.
Treatment history:
For hypertension tab arkamine,Nicardia
For Diabeties Mellitus: Tab Glimi 3Mg/PO/BD
Personal History:
Diet - Mixed
Appetite - Lost
Bowel and bladder movements- Irregular (Constipation)
Sleep - Adequate
Micturition - Abnormal
Addictions:Nill
Family History:
No known member of the family has similar Complaints
General Examination:
Patient is c/c/c
Well oriented to place and time .
No pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers.
Vitals : -
Temperature - 98 °F
Bp - 160/100
Pulse rate - 100/min
Respiratory rate - 16 times / min.
Systemic Examination:
Respiratory system :
Inspection : -
Chest is
bilaterally symmetrical
Movements are bilaterally symmetrical.
Position of trachea Is central
Suprasternal and supraclavicular notching is present.
No Sinuses,Scars,Fistulas
Palpation :
ALL INSPECTORY FINDINGS ARE CONFIRMED BY PALPATION.
Local rise in temperature: No
Non tender
Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .
Percussion:
Resonant sound is heard
Auscultation:
Normal vesicular sounds are heard.
Cvs:
Inspection :
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.
Palpation :
S1 S2 are heard
No thrills , no murmurs
Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .
Auscultation :
Cardiac rate - 100 beats per minute
No cardiac murmurs heard.
Abdomen :
Obese, inverted umbilicus.
Soft,Non tender,No free fluid
No visible scars, sinuses, fistulas engorged veins.
No organomegaly.
CNS:
Conscious, speech is normal
No neck stiffness
Kernings sign - negative
No finger and nose in coordination.
Provisional diagnosis: - Chronic renal failure
Anemia
Resolved heart failure
Investigations:
USG ABDOMEN:
2D echo:
Complete Blood picture:
Complete urine examination: