General medicine case history 2

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DATE OF ADMISSION:17/8/21.

A fifty year old female patient presented to OPD with Chief complaint of back pain since 15 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 15 days back.

Then she complaints of back ache, epigastric pain, leg pain, nausea,urine urgency and burning.

No history of shortness of breath and facial paralysis.

She admitted in hospital and diagnosed it has kidney failure and so dialysis has been done 4 times in 4 days.

PAST HISTORY:

2 yrs back she had suffered from back ache radiating from loin to groin for which she went to hospital and they diagnosed it as kidney related problem and medication has prescribed.

She was on the medication for 2 yrs.

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

She is a hypertensive patient since 2 yrs.

She had undergone uterus related surgery 20 yrs back.

PERSONAL HISTORY:

Apatite: low

Diet: mixed

Sleep: inadequate

Bowel and bladder movement: regular.

No addictions.

FAMILY HISTORY:

There is no history of similar complaints in the family.

TREATMENT HISTORY:

Patient was on these medication:

Nodosta DS 15S Tab

Cifran 500 mg.

Esomefa 40 DSR.

Active D cap.

Lipvas 10 mg

Cilacar 10 mg for 2 yrs.

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 pedal edema and pallor.

VITALS:

Temperature: Afebrile.

BP: 140/70 mmHg.

Respiratory rate: 20/ min.

SPO2 : 99% at room temperature.

Pulse rate: 105 beats/ min.

GRBS: 136 mg%.

SYSTEMIC  EXAMINATION:

CARDIAC 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

INVESTIGATIONS:

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

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