45 year old female chronic kidney disease

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45 year female ,home maker resident of Nereducherla ,suryapet came to casualty with 

C/o -

Low back ache since 2 months

Short ness of breath since 2 months

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 2 months back then she developed low back ache.

She was taken to local hospital and diagnosed as CKD 

After a month ,she started having pain again 

Then she was taken to hospital in miryalguda and they recommended for dialysis.

At the same time  she developed shortness of breath (grade 2(acc. to mMRC)

Then she was admitted in our hospital .

Now she is undergoing treatment .

Number of dialysis- 9

Daily routine:-

Patient wakes up at 6am in the morning and does some daily chores 

Takes tea and rice for breakfast 

And rice for lunch 

Then takes idly or dosa for dinner.

Sleeps at 10pm.

PAST HISTORY:-

K/c/o HTN since 2 months

No k/c/o 

        diabetes

        Thyroid

        Asthma

        Tuberculosis 

        Epilepsy

PERSONAL HISTORY:-

   Diet – mixed 

   Appetite – normal

   Sleep – adequate

   Bowel and bladder movements- regular

   Micturition – regular

  Addictions - no particular addictions

Menstrual history:

Age of menarche- 15 years

 Regular cycles- 5/28

No dysmenorrhea 

FAMILY HISTORY:-

No relevent family history 

DRUG HISTORY:-

Patient used to take tablets for HTN

No known allergy for drugs

GENERAL PHYSICAL EXAMINATION 

Patient was conscious ,coherent  and  cooperative and examined in sitting position in well lit room.

Moderately built  and moderately nourished

                  no pallor

                  no icterus

                  no cyanosis

                  no clubbing of fingers

                  no generalised lymphadenopathy

                  no pedal edema

CLINICAL PICTURES:-

VITALS-

   Temperature – Afebrile

   PR                   - 90 BPM  

   RR                   - 16 breaths/min

   BP                   - 140/80 mm Hg

SYSTEMIC   EXAMINATION-

    I have examined the patient in sitting position

CVS –

   

    S1,S2 heart sounds heard

    No thrills

    No murmurs

RESPIRATORY SYSTEM

On INSPECTION

    Dyspnea – experiences dyspnea

    Position of trachea – central

    No drooping of shoulders 

    No scars 

    Breath sounds – vesicular sounds heard

ON PALPATION:-

All inspectory findings are confirmed 

Position of Trachea - central 

Apical impulse in left 5th inter coastal space ,2cm medial to mid clavicular line.

Vocal fremitus- felt on supra and infra scapular area

           

ON PERCUSSION -

                                 Right           Left

Supra clavicular-       R                 R

Infra clavicular-         R                  R

Mammary -             Dull               Dull

Suprascapular-          R                  R

Interscapular-            R                  R

Infrascapular-            R                  R

ON ASCULTATION:-

                                   Right            Left

Supra clavicular-     NVBS            NVBS

Infra clavicular-       NVBS            NVBS

suprascapular-        NVBS            NVBS

ABDOMEN-

   No scars

    

   No Rise in temperature

   No tenderness

   Shape of abdomen – scaphoid 

   

 CNS-

   Patient is conscious ,

   Speech is normal,

   Memory is intact.

PROVISIONAL DIAGNOSIS:-

Renal failure

Anemia

INVESTIGATIONS:-

On 02/01/2023

TREATMENT:-

Dialysis